States can support access to medicine as COVID-19 Public Health Emergency ends

The United States will soon reach an important milestone in the COVID-19 pandemic: the official end of the federal public health emergency (PHE). According to the U.S. Department of Health and Human Services (HHS), the COVID-19 PHE will expire on May 11, 2023. This significant transition has been made possible, in part, by the biopharmaceutical industry’s continuing efforts to research, develop and manufacture safe, effective treatments and vaccines for COVID-19. The industry leveraged decades of research and investments into developing medical solutions to prevent and treat COVID-19 and remains committed to supporting innovation in this space.  

Congress also recently passed legislation ending continuous and expanded enrollment elibility for Medicaid, which was tied to the COVID-19 PHE, as of March 31, 2023. Beginning in April, many states will begin reassessing eligibility for people served by Medicaid to determine if they are still eligible for the program. Projections indicate that more than 15 million Medicaid participants will need to transition to another source of health coverage, such as commercial health insurance. The process of redetermining eligibility for people enrolled in Medicaid may take as long as a year, meaning many Americans could experience a gap in health care coverage.

People who were enrolled in Medicaid that transition to commercial health insurance are likely to experience sticker shock in what they pay for premiums and cost sharing compared to the nominal, if any, expenses they paid under Medicaid. We know that adherence to needed medication improves health outcomes and reduces care costs, which makes it critical for these people to have continued access to the medicines they need now and throughout the transition period.

In fact, research shows 3 in 10 Americans who have health insurance still face a financial barrier to care, such as struggling to pay medical bills or having out-of-pocket costs they can’t afford. The issue could be even worse for those coming off Medicaid. That’s because insurers and middlemen like pharmacy benefit managers (PBMs) often shift health care costs onto patients through high deductibles and coinsurance.

Here are some commonsense solutions state policymakers should consider as they work to ensure their constituents still have access to and can afford the medicines and health care they need.

Require Standardized Insurance Plans 
State policymakers can address insurers shifting costs onto patients by requiring some health plans offer standardized benefits. Standardized plans can simplify health insurance enrollment by streamlining choices and making the shopping experience more patient-friendly. The types of benefits these plans provide can include setting lower cost-sharing amounts, requiring copayments rather than coinsurance and designating some services eligible for coverage before having to reach a deductible. This would help increase health care access and affordability for patients.

Share the Savings 
In some cases, insurers and PBMs require patients to pay more for medicines than they do. Thankfully, some states are taking action to address these practices by enacting policies that would require insurers and PBMs to base cost sharing on the negotiated price they pay for medicines instead of the list price of the medicines. Just this month, Arkansas became the latest state to pass patient-first legislation to require insurers and their PBMs to share the savings they negotiate on medicines directly with many patients. This means big cost savings for some Arkansans who have not yet met their deductible. Other states should consider this model as they look for ways to help patients access the medicines they need.

Protect Patient Assistance
Most Americans have probably never heard of accumulator adjustment programs (AAPs), but they are programs used by insurers that shift costs onto patients at the pharmacy counter and can ultimately hurt patient outcomes.

Here is how it works. To help commercially insured patients access their medicines and afford rising out-of-pocket costs set by insurers and PBMs, some biopharmaceutical companies offer cost-sharing assistance. Unfortunately, many insurers and PBMs are implementing AAPs to exclude cost-sharing assistance from counting toward patients’ deductibles and out-of-pocket maximums, which can lead to patients paying significantly more at the pharmacy counter than they should be. This could lead patients to simply stop taking their medicines.

States can address this by banning AAPs and protecting patients. Sixteen states have led the way and already passed bans, and others should follow.

Use MAT.org as a Resource 
For additional support, patients, caregivers and health care providers can access the Medicine Assistance Tool (MAT), which is a dedicated search engine that allows people to search for patient assistance resources available to eligible patients through various biopharmaceutical industry programs.

The end of the COVID-19 PHE marks a new chapter in the pandemic and our health care system. States need to act quickly to ensure Americans still have access to affordable health care, including coverage for lifesaving medications.