Opinion | An opportunity to protect patients in Michigan

As of December 2022, six out of 10 adults in the U.S. have a chronic disease. These patients often rely on expensive medications in order to effectively manage their health. 

I am one of these patients. Since 1990, my annual health-care costs have hovered around $1 million. That’s right: a million dollars a year. I’m fortunate that medication exists for my condition, but there is no generic equivalent, no one-pill-fits-all solution. I’m also fortunate that I have health insurance, but it does not pay the full cost of my care. Like many people with a chronic illness, I rely on copay assistance to fill the gap. It is a vital lifeline to otherwise prohibitively expensive treatment.

Unfortunately, insurers and their pharmacy benefit managers have changed the game for patients who use copay assistance. Instead of counting those payments toward our annual cost-sharing limit, they’re diverting them to their own bottom line.

Michigan’s legislature has an opportunity to pass HB 4719 and ensure protection for patients who rely on copay assistance across the state.

This change would do more than just stop pharmacy benefit managers from lining their pockets at the expense of patients, it would ensure better-quality care for patients. In a study published in 2020, IQVIA, a health-care analytics company, examined the problem of patients abandoning their prescriptions. "While abandonment rates are less than 5% when the prescription carries no out-of-pocket cost, it rises to 45% when the cost is over $125 and 60% when the cost is over $500," the report said. By addressing copay assistance accumulator programs, we can help address treatment abandonment as well.

Thankfully, leaders across the country are acting on this important issue. Laws banning copay assistance diversion programs have been put in place in 20 states, the District of Columbia, and Puerto Rico. Now it is time for Michigan to join these states and codify these crucial protections for patients.

While state laws help a lot of people, they don’t help everyone. Employer-sponsored insurance plans fall under federal jurisdiction, meaning we need federal legislation to extend these protections to every insurance plan.

Thankfully, the federal bipartisan HELP Copays Act (HR 830 and S. 1375) aims to solve exactly that issue. This act would ensure that any amount paid by, or on behalf of, a patient is counted towards the patient’s deductible, co-insurance, co-payment, or limit nationwide.

For patients like me, this change would be nothing short of life-changing, removing a persistent barrier to accessing essential medication. Throughout my life, I’ve faced countless challenges due to inadequate coverage, from having to move closer to specific health-care facilities to having to turn down promising job opportunities out of fear of losing health-care benefits. I’ve even been terminated from jobs solely because of the high cost of my health condition.

Over the years, I’ve become familiar with the tactics and loopholes used by insurance companies to deny or limit coverage. It is a constant battle to get the health care I need to survive. But the reality is patients should not have to navigate this labyrinth just to get necessary care.

Patients battling illness or managing a chronic condition deserve to focus on their health, not battle their insurers and pharmacy benefit managers to get the care they need. The current system places an unfair burden on patients, making it hard to get the medications prescribed by our doctors, and hard to afford them even after they’ve been approved by the insurer and pharmacy benefit manager. Today, children born with my condition have an opportunity to grow up healthy and thrive because of advances in treatment.  They have the chance to never experience the physical pain and suffering that is my life.  Roadblocks to accessing these medications by the insurance companies should not be part of their life either.   

We can’t delay any longer, this issue has real impacts on vulnerable patients across Michigan. I am calling on Senators Gary Peters and Debbie Stabenow to fight for the HELP Copays Act, and for our state leadership to pass HB 4719. Through these vital pieces of legislation at the state and federal level, patients across the state will finally be fully protected from these harmful practices.