Congress Should Protect Premium Assistance for Individuals Living with Chronic Conditions

Congress took an historic step to prevent health insurers from discriminating against patients with pre-existing conditions when it passed the Affordable Care Act (ACA). Unfortunately, recent guidance from the U.S. Centers for Medicare and Medicaid (CMS) may be inadvertently creating a new ‘pre-existing condition’ that is keeping essential treatments and services out of reach for patients who need them the most.

For individuals living with chronic and life-threatening illnesses, the costs to simply maintain their health insurance can be prohibitive. For many of those individuals and their families, charitable non-profit premium assistance programs step in to provide a temporary safety net to patients who couldn’t otherwise afford their high premium payments each month – a service that can often mean the difference between life and death. These critical programs not only help to maintain the health and financial stability of the patient, but they do so with charitable donations rather than through precious government or taxpayer funds.

Yet, when CMS issued federal guidance on third-party insurance payments for the new Exchange plans offered under the ACA in 2014, it failed to include non-profit charities on the list of acceptable arrangements for patients covered by qualified health plans. Exemptions have been extended to Ryan White HIV/AIDS Programs, Indian Tribes, and other state and federal programs – but not nonprofit charities. The CMS guidance is in direct contradiction to the standard currently followed by Medicare.

As a result of CMS’ failure to include nonprofit charities as an acceptable third party premium payment arrangement, health plans across 38 states are now denying coverage to patients by rejecting the assistance they receive from nonprofit third parties. Without concrete action to reverse this harmful guidance, insurers in other states will likely follow suit, which will jeopardize the health of vulnerable patients nationwide.

Fortunately, Congress now has a chance to take action to help ensure that patients have access to the treatments and services they need. The Access to Marketplace Insurance Act (H.R. 3742), introduced by Rep. Kevin Cramer (R-ND), is bipartisan legislation that would create a carve-out for nonprofit charity organizations to continue providing premium assistance under the Affordable Care Act.

As someone living with both hemophilia and HIV – the latter due to poor government decision-making in blood collection policy (IOM Study 1995) – I understand firsthand the financial pressures that come with treating chronic medical conditions. That is why I established Patient Services Inc. in 1989 to help ensure patients living with devastating diseases don’t have to live in fear of defaulting on their premium payments.

But with this premium assistance now in jeopardy, I fear that the government has not learned from previous poor policy decisions.

When patients cannot afford their health insurance and are unable to access health care, it is not only their health that suffers. When care becomes too expensive for patients and their families, many lose their insurance or are forced to declare bankruptcy; many enroll in government programs; while others visit hospitals for primary care, adding to uncompensated care costs, which are often paid for using tax dollars.

No patient should have to choose between paying for insurance and paying their rent or providing food for their families.

The aid that PSI and other non-profit assistance programs provide helps these patients bridge the financial gap that their insurance does not meet, making it possible for them to manage their conditions and lead productive lives – at no added cost to the public. These premium assistance programs go a long way towards keeping the financial burden off not only the patient, but the taxpayer as well.

By failing to include nonprofit charities on the list of acceptable third-party payers, CMS has effectively prevented charities from being charitable and has enabled insurers to deny coverage to patients with serious conditions – undermining the original intent of the ACA. Not being able to afford your insurance premium should not be a new pre-existing condition.

Congress should take action now to pass the Access to Marketplace Insurance Act. This bill is a common sense, bipartisan solution to correct the harmful CMS third-party guidance. By passing this critical legislation, Congress can ensure that Americans living with chronic conditions have access to the care that they need.

Dana A. Kuhn, Ph.D., is the founder and president of Patient Services Incorporated (PSI), a non-profit charitable organization that helps patients find health insurance and then provides or subsidizes the cost of health insurance premiums/co-payments for persons suffering from specialized expensive chronic illnesses.

Morning Consult