ACA coverage may be inadequate for chronically ill

Most Americans insured through exchanges who reach out-of-pocket maximums will be underinsured, despite Affordable Care Act subsidies and lower out-of-pocket caps, according to an analysis by Avalere Health.

"Patients with high healthcare needs ... will still face considerable expenses before they reach the cap," said Caroline F. Pearson, vice president at market analysis firm Avalere Health. "These costs could result in inadequate or inconsistent care for high-need, low income exchange enrollees." 

Chronically ill adults enrolled in skinny (or bronze-level) insurance plans are apt to reach out-of-pocket maximums annually, Avalere Health noted.

Prescription drug utilization can lead to skyrocketing costs for the chronically ill: Patients on expensive drug regimens for conditions including hepatitis, rheumatoid arthritis, HIV and cancer can incur thousands of dollars in monthly costs, with some exchange plans requiring enrollees to pay up to 50 percent of the costs, according to The Wall Street Journal.

Increased exposure to healthcare costs also raises barriers to care: More than one fourth of chronically ill adults who regularly take prescribed medications skipped does or didn't fill their prescriptions since they couldn't afford them, a Commonwealth Fund survey found.

To control costs without discriminating against the chronically ill, insurers offering exchange plans may place costly prescription drugs in top formulary tiers requiring large co-payments, the WSJ noted. And "people may be attracted to [exchange] plans with low premiums and not have much coverage at all," Kimberly Beer, director of advocacy for the Arthritis Foundation, told the WSJ.  

Although drug companies, government programs and foundations offer prescription drug payment assistance, whether these discounts will be allowed for exchange products is unknown. Payers say these discounts thwart efforts to steer customers to less costly alternatives, and that the discounts are barred in government programs as illegal kickbacks, the WSJ reported.   

Overall, the design of exchange benefits plans available to chronically ill Americans "raises important questions about what we want insurance to be, and invites a discussion of the rules under which exchange plans will operate," said Avalere CEO Dan Mendelson.

For more:
- read the Avalere Health announcement
- here's the Wall Street Journal article
- see the Commonwealth Fund survey (.pdf)

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