Why affordability matters
Medical advances don’t mean much if the people who need them most can’t afford them. But that’s the reality for millions of people today—even those with employer-sponsored health insurance or Medicare. Rising premiums, deductibles, co-pays, and coinsurance are leaving more Americans than ever underinsured and unable to afford treatment.
Recent surveys show that due to high out-of-pocket costs, a rising number of Americans:
- Don’t go to the doctor when they’re sick
- Skip routine preventive care
- Take less of their medication or don’t fill their prescriptions at all
- Forgo recommended medical tests, treatments, and surgeries
According to the Kaiser Family Foundation, 50% of U.S. adults say they or a family member delayed or skipped health or dental care, or relied on an alternative treatment, in the past year due to cost.
PAN and other charitable patient financial assistance programs provide a critical safety net for many of the most vulnerable people with serious health conditions. But it’s not enough.
Unless we change the system, the situation is likely to only get worse. A recent Kaiser Family Foundation report predicts that by 2030, people with Medicare coverage and incomes below $10,000 will spend more on out-of-pocket healthcare costs than the average Social Security income.
Put patients first to improve healthcare access and affordability
The problem of healthcare access and affordability is complex. But solutions are possible. Below are the key ways we believe we can put patients first—and make sure that high costs never stand between anyone and the care they need.
Out-of-pocket costs should not prevent individuals with life-threatening, chronic, and rare diseases from obtaining their prescribed medications.
Within today’s healthcare delivery system, charitable patient assistance programs provide a critical safety net for ensuring access to medically necessary treatment.
Out-of-pocket costs for prescription medications should be capped by instituting monthly or annual limits.
Out-of-pocket costs for prescription medications should be spread more evenly throughout the benefit year.
All conditions should have at least one highly effective innovator drug on a fixed co-payment tier.
The Medicare Part D structure should be modernized to reflect the current prescription drug landscape. Changes to the benefit design should improve access to medications for Medicare Part D beneficiaries.
The Medicare Part D Low-Income Subsidy (LIS) program should be modernized to increase enrollment and provide continuity for individuals from one year to the next.
Vaccine co-pays should be eliminated under Medicare Part D.
Medicare should be expanded to include dental, hearing, and vision benefits.
Public and private health insurance deductibles should not be set at amounts that preclude patients from accessing treatment for life-threatening, chronic and rare diseases.
Co-pay accumulators or similar programs lead to greater out- of-pocket costs for individuals with life-threatening, chronic and rare diseases and should be prohibited.
Value-based insurance designs (VBID) that increase access to treatment for individuals living with life-threatening, chronic, and rare diseases should be encouraged.
The total out-of-pocket cost of care must be taken into consideration when developing policy solutions to decrease the financial burden of care and treatment for Americans.
Public and private insurers should adopt policies that address social determinants of health to mitigate barriers that prevent patients from adhering to their medications.