by: Sen. André Jacque and Rep. Paul Tittl | April 17, 2021
The health and economic impacts of the ongoing pandemic have left many of the most vulnerable in Wisconsin struggling to get by. For individuals with a complex disease, it’s not just that they’re at greater risk from COVID-19. The financial impact of the last 12 months has left many stressed and wondering how they will afford their groceries, mortgage and the prescription medications that keep their health stable.
Many of these patients rely on copay coupons and vouchers to afford their prescribed treatments at the pharmacy counter. But a new health insurance tactic is blocking that copay assistance from counting toward their out-of-pocket expense or deductible.
Wisconsin can take a step forward in our efforts to protect individuals from rising health care costs by ensuring that health plans count copay assistance toward a patient’s maximum out-of-pocket cost or annual deductible. Copay assistance programs often act as a lifeline for patients to afford specialty medications they require to treat a medical condition. These programs have become more essential to patients in recent years, because they are more frequently bearing the burden of higher out-of-pocket costs for their health care.
In 2020, the average deductible for single coverage was $1,364, which is a 364% increase from 2006. Over the past five years, the percentage of covered workers with a general annual deductible of $1,000 or more for single coverage has grown from 23% to 57%. Further, in 2020 more than one in four covered workers was enrolled in a plan with a deductible of $2,000 or more.
But as patient costs increase, health plans are finding ways to turn those costs into more profits. Insurance companies are more frequently including policies in their plans that do not count the value of copay assistance programs toward a patient’s out-of-pocket costs. In essence, the coupon card does nothing to help patients pay down their deductibles. Insurers double dip, and patients often have to make tough financial decisions to access their prescriptions. Or, worse — they stop taking their medication.
Data shows that high out-of-pocket costs lead patients to increasingly abandon their medication. One study found that more than 40% of patients abandoned their prescriptions at the counter when their out-of-pockets costs reached between $75 and $125. The same study found that when those costs hit $250, over 7 in 10 patients walk away from their therapy.
Wisconsin insurers will argue that copay assistance is unnecessary because patients have access to generic equivalents to their medication. But the facts show the vast majority – 87% – of patients who look to copay assistance have no generic options on the shelf for their treatment. If the goal of these policies is to save costs, think again. When patients can’t afford their medications and choose to skip doses or stop treatment, it can lead to costs in the overall health care system.
A new proposal in front of the Wisconsin Legislature would ensure that the copay assistance programs patients use to afford their medications count toward their out-of-pocket costs. Senate Bill 215 and Assembly Bill 184 would still give Wisconsin insurers flexibility with their plans, while making sure patients can continue to afford the medications they need.
This is not an effort to enforce another health insurance mandate, but simply protects patients who rely on copay assistance by applying it toward their out-of-pocket requirements. It’s about giving patients peace of mind when they walk up to the pharmacy counter that they can pay for their prescriptions. If you have cancer, epilepsy or any other serious medical condition, the last thing you should have to worry about is how to pay for your life-saving medication.
Sen. Jacque, R-De Pere, represents Senate District 1: email@example.com. Rep. Tittl, R-Manitowoc, represents Assembly District 25: firstname.lastname@example.org.