Copays and coinsurance fees are higher for many under the ACA

February 27, 2014

By Sara Gilgore


The Affordable Care Act’s new health insurance plans do cover prescriptions, but they might be less affordable than anticipated.

Copayments and coinsurance fees have increased 34 percent under the ACA, according to a recent study from HealthPocket, an unaffiliated research company that provides health-plan comparisons. The law now requires that prescription drug coverage be included with the plans offered in the individual- and small-group markets under the ACA. But out-of-pocket fees for these prescriptions are higher than previously.

Clare Krusing, spokeswoman for America’s Health Insurance Plans, said Thursday the reform adds new benefits and new costs to coverage, and the plans must cover a mandated number of services.

“As all those benefits and costs are added to coverage,” Krusing said. “That does make coverage more expensive. It’s more comprehensive and more expensive than what some people may have been purchasing previously.”

The study found that of the people who enrolled in the online health care exchanges, those who use multiple prescription drugs will be most noticeably affected by the fee increases, compared to individuals who do not take medications frequently.

Josie Martin, executive vice president of public affairs for Pharmaceutical Research and Manufacturers of America, said Thursday she fears the rising costs for patients who rely on prescriptions could diminish advancements in health care. As examples, she cited reductions in heart attacks, expensive hospitalizations, expensive bills, loss of work and trauma to families.

“In chronic conditions like heart [disease] or diabetes, where there are medications to manage conditions, we’re really concerned that all of the progress that’s been made in the last 10 years could be lost,” Martin said. “People are going to have trouble adhering to their medications if they are out of reach financially.”

When patients are confronted with higher copays and coinsurance fees, they might not fill their prescriptions. According to Martin, people who are prescribed drugs that could “keep them out of expensive hospitalization situations, and keep them at work, and with their families, and keep them alive” might be deterred by the higher costs.

“If they can’t afford it, it makes it very difficult for them to know what they are supposed to do,” Martin said. “We’re worried about people not taking their medications.”

Health care costs have jumped partially because prescription drug prices are rising, Krusing said, which is “putting a burden on patients.”

Health plans have focused on providing access to medications, and the rise of generic drugs has saved millions of dollars for consumers, Krusing said.

“It’s a whole package of promoting prevention and wellness, and making sure that patients have access to medication that they need… [and] that they can stick with a routine that is safe, effective and affordable for them,” Krusing said.

However, the pharmaceutical industry views the hikes in out-of-pocket fees as a conceivable threat to a patient’s access to “cutting edge medicine,” according to Martin.

“That’s our big concern,” Martin said, “people’s access to the medication that they’re currently taking, and access to what they might need down the road, because you never know what’s going to happen.”

The true impact of higher copays and coinsurance fees – on the health care industry, the pharmaceutical industry and patients – remains unknown. But as people fill prescriptions and switch to new plans, anecdotal information and data will become available over time, Martin said.

The open enrollment period to register for plans in the online marketplaces continues until the March 31 deadline.