As a State Representative, I have spoken to a number of families who have very real concerns about how they are going to pay their medical bills when the price on everything from milk to eggs is going through the roof. I believe strongly that we have to embrace innovative ways to ease the financial burden on Missouri families, particularly vulnerable people who are impacted by chronic disease.
In recent years, new drugs and medical technologies have vastly improved the lives of individuals with challenging diseases like cancer, cystic fibrosis, multiple sclerosis, and diabetes. In just the past year, ten new cancer treatments have been approved by the FDA, as well as a new, life-saving therapy that will help treat the underlying cause of cystic fibrosis in thousands of patients.
For complex, chronic illnesses the price of these specialty treatments is often high, even before taking into account the runaway inflation that is now gripping America. This puts individuals with a high deductible in a tough position – they must either find a way to afford the expense (often by cutting back spending on basic necessities like food and rent) or they have to go without medications that could drastically improve their health and their quality of life.
Until the past few years, many of these families had a solution – pharmaceutical manufacturers and non-profits operated co-pay assistance programs to reduce out-of-pocket costs for patients and help them hit their deductible, at which point insurance coverage would kick in.
However, not long ago, Pharmacy Benefit Managers (PBMs) found a way to pass along more costs to consumers. By declaring these treatments “non-essential” they were able to put them under what are called “co-pay accumulator” or “co-pay maximizer” programs, exempting any funds that consumers received through co-pay assistance programs from applying to their deductible. The “non-essential” designation means insurers will not cover a brand-name pharmaceutical, but in the vast majority of cases in which co-pay assistance programs are applicable (80%) there are no generic options available. This means that PBMs are taking away money-saving options from consumers for no good reason.
Unfortunately, most people impacted do not know about their health plan’s co-pay accumulator program until it’s too late and they are hit with an unexpected bill. In too many cases, these individuals have no financial alternative but to discontinue treatment while they deal with the impact of a bill they did not expect to receive.
This is not a choice that anybody in Missouri should have to make.
In sixteen states, lawmakers have addressed this problem by placing limits on the use of co-pay accumulators by Pharmacy Benefit Managers, and that is exactly why I have sponsored a bill to do the same, HB442. Federally, there is a bipartisan bill that would solve this issue nationally – HR5801, the Help Ensure Lower Patient Copays Act. I am hopeful that our state will join the growing list protecting citizens from co-pay accumulators, and I urge our delegation in Washington to support a federal solution to this important issue.
Representative Dale Wright, a Republican, represents portions of St. Francois, Ste. Genevieve, and Perry Counties (District 116) in the Missouri House of Representatives. He was elected to his first two-year term in November 2018.