(Bloomberg) — A quarter of plans under the Patient Protection and Affordable Care Act effectively discriminated against AIDS patients in 2014 by requiring high out-of-pocket payments for all HIV drugs in a key class, Harvard University researchers found.
Their small study, published in the New England Journal of Medicine, examined AIDS drug costs in 48 plans under Obamacare in 12 states, including Florida, Michigan, New Jersey and Pennsylvania. Twelve of the plans from seven different insurers forced AIDS patients to pay 30 percent or more of the cost of all drugs in the class, a practice that may deter patients with HIV from enrolling in those plans.
The study also could have implications for people suffering from other diseases that require treatments with expensive drugs.
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"Our findings suggest that many insurers may be using benefit design to dissuade sicker people from choosing their plans," authors Douglas Jacobs and Benjamin Sommers, both of the Harvard T.H. Chan School of Public Health, said in the study.
The analysis underscores a federal civil rights complaint made last May to the U.S. Department of Health and Human Services by the AIDS Institute and the National Health Law Program. It contended that four carriers in Florida, including Aetna Inc., were discriminating against AIDS patients in some of their Affordable Care Act plans by putting all HIV medicine in the highest drug payment tiers, which often require steep out- of-pocket payments based on a percentage of a drug's cost.
Florida pattern
The findings show that the pattern seen in AIDS drugs in Florida has been occurring in many other states, including New Jersey, Michigan, Utah, South Carolina, Pennsylvania and Louisiana, Jacobs and Sommers said in an interview. The Harvard study examined mid-level "silver plans" in 2014 and didn't look into whether the limitations continued to occur in 2015.
"This reconfirms what we have been saying and seeing," said Carl Schmid, deputy executive director of the AIDS Institute, which is based in Tampa, Florida. "There is obviously discrimination out there."
Plan designs that left AIDS patients with no low out-of- pocket cost drug options were "fairly widespread," said Jacobs, a public health student at Harvard and the study's lead author. "It seems to be a very significant problem."
Potential solutions
In November, the Department of Health and Human Services issued proposed guidance for 2016 that would make it harder for insurers to require high out-of-pocket costs for all drugs for a chronic condition. The rule would more clearly define that type of requirement as discrimination.
"If an issuer places most or all drugs that treat a specific condition on the highest cost tiers, we believe that such plan designs effectively discriminate against, or discourage enrollment by, individuals who have those chronic conditions," according to the proposed guidance.
The researchers suggested ways officials could go further. One solution is for the federal government to create certain protected drug classes for which there would be an upper limit on what insurers could require patients to pay, the Harvard researchers wrote in their article. It may also make sense for the government to require insurers to cover a certain minimum percentage of overall drug costs, they wrote. This would force carriers to lower out-of-pocket costs for some drugs if they raised them on others.
Still waiting
Companies named in the Florida civil rights complaint last May included Aetna, Humana Inc. and Cigna Corp. Schmid said that while those insurers have reached agreements to lower AIDS drug costs for patients in Florida, the broader issue of what is allowed nationally under PPACA remains unresolved.
"We are still waiting" for the federal complaint to be resolved, said Schmid, who is based in Washington.
In a statement, Aetna, based in Hartford, Connecticut, said it has voluntarily updated its plans in order to ensure compliance with Florida law. The plans now puts all generic HIV drugs on the non-preferred generic tier, Aetna said.
Humana, based in Louisville, Kentucky, said as part of an agreement with Florida insurance officials, it moved all generic and brand drugs that cost under $600 a month off the specialty drug tier for its 2015 PPACA plans in that state.
Cigna, based in Bloomfield, Connecticut, said in November it voluntarily agreed to move all generic drugs that had been on the specialty tier in Florida exchange plans to a lower tier, and it also capped monthly costs for four brand name HIV drugs for the plans in that state.
The Harvard study found four additional insurers not named in the Florida civil rights complaint had plan designs that may discriminate against AIDS patients, Jacobs said. The study doesn't name the insurers.
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