Op-Ed | Why Congress must take the lead on co-pay accumulators

20230302_Bronx Times_Jacobi Hospital Nurse Rally_Perez, Paige_428_03
Jacobi Medical Hospital has faced the loss of 183 nurses in 2022 – roughly 20% of its workforce.
Photo Paige Perez

COVID exacerbated many existing problems. With inflation at a 40-year high we must help alleviate the dire financial situation faced by many of our most vulnerable neighbors: those impacted by chronic disease. That is why I was a proud co-sponsor of legislation, which recently became law, that bans co-pay adjustment programs, which is yet another way for insurance companies to enrich themselves at the expense of sick patients.

So many amazing medical advancements have taken place over the past 20 years to treat cancer, ALS, hemophilia and lupus. New drugs have been approved to address Type 1 diabetes and cystic fibrosis. But none of the drugs help if they are not accessible, and the biggest problem is cost.

Until recently one of the solutions to this was that pharmaceutical manufacturers and nonprofits stepped in to support patients and families with co-pay assistance programs, helping to reduce out-of-pocket payments for medication and treatment. These savings were intended to be put toward a patient’s insurance deductible, allow them to hit their out-of-pocket maximum, and have insurance cover the rest.

Unfortunately, insurance companies and Pharmacy Benefit Managers (PBMs) found a loophole in laws that were meant to ensure people have access to lifesaving medicine and decided to categorize new treatments as “non-essential” despite the fact that for 80% there were no generic options available. Insurers don’t have to count funds given by third parties for “non-essential” drugs toward peoples’ deductible. They happily accept the money from assistance programs to support patients, but they then force patients to pay thousands more to reach their out-of-pocket maximum.  

Most people impacted didn’t know their health plan had a co-pay accumulator or maximizer program until they got hit with a surprise bill showing that they owed money after they thought they satisfied their deductible.

Legislation that I co-sponsored passed by the Assembly and the state Senate and signed into law by the governor update our laws to prohibit insurers and PMBs from continuing this awful practice and enable patients to access and afford the lifesaving medications they need to manage their chronic illnesses. I hope Congress follows our example and closes the same loophole on a national level to protect the health and  financial stability of families. The proposed ban on co-pay accumulators would ensure patients receive the treatments they need without facing undue financial burdens and make a difference in the lives of countless patients and their families.

Jeffrey Dinowitz is a Bronx state Assemblymember. 

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