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When coverage does not equal access to care

Karyn Schwartz   |     February 19, 2016   |   SHARE THIS

ABC-logo.pngBuilding on recent stories about the challenges even those with insurance are facing, new data show some consumers have no choice but to pay up to thousands of dollars out of pocket before their medicines are covered if they enroll in one of these plans. The high deductibles required by many marketplace plans have already gotten a lot of attention, and many consumers have been surprised to find out that they have to pay the full cost of their medicines until they reach a deductible of $3,000 or more.

In 38 percent of the rating areas in the United States in 2016, none of the silver plans offered in the marketplace cover all medicines before enrollees reach the plans’ deductible.[1] And, combined deductibles for silver plans are expensive. The average combined deductible (meaning, the plan has a single deductible for medical and prescription drug costs) for silver plans is $3,064 in 2016. This means consumers unlucky enough to live in one of these areas did not have a single silver plan to choose from that would let them access their medicine by paying a copay or coinsurance without first meeting the plan’s deductible.

For 2016, in Arkansas, Hawaii, Kansas, Maine, Nevada, New Mexico, Oklahoma, Virginia and Wyoming, every silver plan in the entire state subjected medicines to a deductible. In Arizona and Georgia, only one rating area in each state has any health plans that offer coverage for medicines before the deductible is reached.

For some patients, the out-of-pocket cost barrier may force them to forego their medicines altogether which could have harmful implications for their health and result in other health complications. In fact, past research has shown that higher cost sharing is associated with lower adherence and may increase racial disparities.[2] These new data raise concerns that many consumers are being forced to pay thousands before their medicines are covered simply because they are unlucky enough to live in an area with limited additional coverage options.


 [1] Avalere Health analysis for PhRMA of the Centers for Medicare & Medicaid Services’ Marketplace Public Use File (PUF), which contains information for the 38 states participating in the Federally Facilitated Marketplaces (FFM) for 2016. The PUF file was limited to silver plans and refined to consistently define deductible and tiering information, though it does not necessarily reflect when certain tiers are exempt from the deductible. This analysis categorizes a plan as having first dollar drug coverage if its refined drug deductible amount equals zero or its refined drug deductible is “included in medical” and the medical deductible equals zero.

[2] N.K. Choudhry, et al. “Eliminating Medication Copayments Reduces Disparities In Cardiovascular Care.” Health Affairs vol. 33, no.5 (2014):863-870; Lewey J, Shrank WH, Avorn J, Liu J, Choudhry NK. Medication adherence and healthcare disparities: impact of statin co-payment reduction. Am J Manag Care. Oct 2015;21(10):696-704.

Karyn Schwartz

Karyn Schwartz Karyn Schwartz is a deputy vice president in the policy and research department at PhRMA, where she has responsibilities for policies related to the Affordable Care Act, Medicaid and the 340B program. Prior to joining PhRMA, she worked at the Department of Health and Human Services and the Kaiser Family Foundation. When not immersed in arcane policy details, Karyn enjoys going for early morning runs and exploring Washington, D.C. with her twin boys.

Topics: Access, health insurance, coverage, out of pocket costs, Access Better Coverage

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