Making "Patient Protection" Essential in Obamacare

For decades, Americans have demanded a healthcare system that provides lifelong access to affordable care. The Patient Protection and Affordable Care Act looked to be a huge step in that direction.

However, recently issued regulations for implementing healthcare reform are threatening to undermine the Act’s fundamental goal of achieving health equity — especially for marginalized racial, ethnic and sexual minority groups. Specifically, health officials have inadvertently or otherwise made some mistakes while developing the new rules that will govern insurance benefit standards.

Congress needs to act now to fix these flaws. If it fails to do so, people living with HIV — as well as millions of other Americans — could be denied essential healthcare services and treatments.

In February, the Department of Health and Human Services (HHS) issued a set of regulations on the essential health benefits (EHB) that insurance plans must cover beginning in 2014. Unfortunately, the EHB rules fall well short of what is truly “essential.”

In the Medicare Part D drug benefit, for example, there are six official “protected” classes of pharmaceuticals — anti-psychotics, anti-convulsants, anti-depressants, anti-neoplastics, anti-retrovirals, and immunosuppresants. And Part D insurers are required to cover most or all of the medicines that fall into these categories.

The EHB rules, unfortunately, do not require insurers participating in the healthcare marketplaces (Exchanges) or state Medicaid Benchmark plans to provide coverage for most of the treatments in each class.

This lack of consistent treatment access and insurer requirements has significant implications for people living with HIV, who often require different approaches to combination therapy. That’s why providers and patients, not insurance companies, need to be empowered to determine which medicines work best to manage their condition.

Modern pharmaceuticals have transformed an HIV diagnosis from a death sentence to a manageable chronic condition. For people living with HIV and other chronic conditions, access to effective and proven treatment regimens is essential. The irony is that the Essential Health Benefit rules will likely deny access to these regimens and, as a result, some people could see their condition and prospects for a productive future deteriorate.

Redressing these gaps in EHB coverage is essential for patients — and it makes good fiscal sense.

A recent study published in the Journal of the American Medical Association found that the expansion of pharmaceutical access to seniors under Medicare Part D saved $12 billion annually in hospitalization and nursing home costs. Getting patients of all ages the drugs that they need helps them to avoid developing more costly conditions in the future — and ultimately helps to contain healthcare spending over the long term.

Although HHS has failed to address these flaws in the EHB rules, there is still an opportunity to act. The EHB rules specify the establishment of an appeals process so that patients in need of treatments that aren’t covered can petition to have them paid for. Though HHS has yet to define how the appeals process will operate, the top priority should be for patients in need of coverage to get it quickly and with a minimum of red tape.

And just as with Medicare Part D, people getting their coverage through the new Exchanges or through expanded Medicaid should also be allowed access to necessary medicines and treatments while they are petitioning for coverage.

If HHS fails to establish a sufficiently robust appeals process, the Centers for Medicare and Medicaid Services agency needs to issue its own regulatory guidance to bulk up the appeals mechanism. Doing so will ensure that patients will have some legal recourse if they’re denied access to vital medicines.

HealthHIV is not alone in expressing serious reservations about the EHB rules. The Arthritis Foundation, the National Alliance for Mental Illness, the Parkinson’s Action Network, and more than a hundred other patient advocacy groups have raised these and other concerns.

HHS needs to comprehensively and quickly address the problems with its EHB rules. Meanwhile, department officials must ensure that the appeals process is robust and patient-friendly. If HHS fails to act, Congress needs to take action to explicitly guarantee patient access to important medications. Inaction will limit access to the medicines that people living with HIV and other chronic conditions need to survive and thrive, keeping the promise of Obamacare from becoming a reality.

Brian Hujdich is the executive director of HealthHIV in Washington, D.C., one of the nation’s largest HIV nonprofit organizations.

–Brian Hujdich





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