To Fulfill the Promise of a Secure, Affordable Health Care System for All, We Must Focus on Benefit Design

It is undeniable that the health and economic stability of many people has been hard hit due to COVID-19. But far before the pandemic, Americans had been hard hit by the persistent health inequities that plague our system. While there are many causes and symptoms of health inequity, one growing area of concern is the difficulty that many working, insured Americans have in affording health care, particularly the out-of-pocket costs they are required to pay by their health plans in order to maintain or improve their wellbeing.

According to a recent Gallup poll, roughly 1 in 5 adults, or nearly 46 million Americans, including 29 percent of Black people and 21 percent of Hispanic people, report that if they needed to access quality health care immediately, they would not be able to pay for it. This concern has real-world implications and further illustrates the ongoing challenges of economic and racial disparities in health care.

In the case of prescription medicines, those who require monthly treatments or specialized medicines face persistent financial barriers – including separate prescription drug deductibles, out-of-pocket costs exceeding thousands of dollars and unaffordable co-insurance – that ultimately force some Americans to forego their medicines at the pharmacy counter and often require even more costly medical interventions later on.

For more than a decade, the cost of insurance premiums has been the ultimate barometer of patient affordability – but premiums alone don’t capture the true cost of being insured. Data from Kaiser Family Foundation documents the variety of new ways in which patients are exposed to cost-sharing, and it’s easy to see how the measure of affordability is more complex than ever before – and more unpredictable for patients.

Focusing attention on health insurance benefit design and looking more holistically at affordability – not just premiums – is important if we are to address inequities across the health system. For example, it’s estimated that roughly 600,000 Americans die each year from cancer and more than 650,000 die each year from heart disease. Between a quarter and a third of these deaths are preventable with proper screening, diagnosis and treatment – and for that to work we need to ensure that patients can afford their drug coverage and that benefit design allows for them to affordably access treatment.

Studies have shown that despite the rise in high-deductible health plans, which were created to reduce health care spending and premiums, nearly half of Americans who have them are not saving for health care costs, shopping for better prices and talking to their doctors about costs. Ultimately, consumers are still struggling with matching economic behavior with the benefits of their health care decisions. A 2021 paper published by the National Bureau of Economic Research found that for each percentage point increase in coinsurance rates, patients make approximately 6 to 19 percent fewer fills on critical long-term therapies. Cost shifting to patients may make sense for one or more entities involved in the complex health care payment system, but ultimately the individual patient will suffer as the nationwide cost of health care increases.

According to that same Gallup poll, more than 80 percent of Americans are in favor of setting caps on out-of-pocket costs for both prescription drugs and general health care services for Medicare beneficiaries. I for one, fall into this majority and agree that we should indeed push for prescription drug caps — but we should not stop at just Medicare. To fulfill the promise of stable, secure and affordable health care for everyone in our country – including the most medically vulnerable – we must expand the concept of patient cost caps across the entire commercial health care and insurance market.

In the midst of a global health care crisis, we must come together to implement meaningful policy changes. I urge policymakers and legislators across this nation to have a real conversation about the ways in which we can ensure health care benefits are working to keep people healthy and benefit design is truly patient-centric.


David Senior is the senior vice president of market economics for AmerisourceBergen, a leading global health care company.

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