Washington Should Cap Out-of-Pocket Expenses for More Seniors with Chronic Conditions

Rising out-of-pocket costs are a burden for many Americans and their families, and seniors who are living with HIV/AIDS, arthritis and any other chronic condition often feel the impacts most acutely. High costs at the pharmacy counter force many patients to ration their medication, skip doses or stop taking medications altogether, which can result in poor health outcomes and increased costs down the road.

Recently, the Trump administration took a positive step in making care for seniors more affordable by capping out-of-pocket costs for insulin in Medicare Part D. Now, to help other vulnerable senior populations access the care they need at an affordable price, federal policymakers should move to expand the Part D out-of-pocket cost cap on insulin to more medications that America’s seniors rely on.

In recent years, the high cost of insulin has taken on increased national attention and urgency. Patients have struggled to afford the critical medication to manage their diabetes, with many going to such extreme lengths as driving to Canada to purchase it. It even became the subject of multiple congressional hearings in the past year. In response, 10 states have passed legislation to cap out-of-pocket costs for insulin, with New Mexico limiting monthly co-pays to $25, the lowest cap yet.

In late May, the Trump administration followed the lead of these states by instituting a cap on out-of-pocket insulin costs for Medicare Part D beneficiaries at $35 for a month’s supply of all types of insulin. Seniors in Part D will be able to choose a plan for 2021 that offers this benefit. This is great progress for the millions of seniors living with diabetes and will result in a 66 percent reduction in out-of-pocket costs – or $446 – for each individual patient, according to Centers for Medicare & Medicaid Services estimates.

But many Americans agree it doesn’t go far enough. According to one recent poll, 75 percent of adults support legislation that places a cap or limit on what seniors pay out-of-pocket for prescription drugs in the Medicare Part D program.

Today, six in 10 Americans live with at least one chronic condition, and four in 10 live with multiple conditions. Seniors are even more affected – 85 percent live with at least one chronic condition, and 60 percent have at least two chronic conditions. People who manage more than one chronic condition experience the greatest financial impact from rising out-of-pocket costs, paying four times more out-of-pocket than those who do not have a chronic condition.

Those living with HIV are particularly impacted. The high cost of HIV treatments limits access to crucial medications and is affecting our ability to combat the epidemic. Of those living with HIV, 7 percent report that cost is preventing them from properly adhering to medication, which can have terrible health consequences.

When patients skip doses of HIV treatment, it can cause the disease to change forms and lead to drug resistance. When HIV becomes resistant to the medication a patient is taking, it can also become resistant to similar medications they have not yet taken, which can greatly limit treatment options. Moreover, these drug resistant strains of HIV can also be transmitted to others, which has the potential to make new outbreaks difficult to contain.

HIV is merely one of many chronic diseases that can cost Medicare Part D beneficiaries thousands of dollars out of pocket annually. For those living with conditions like rheumatoid arthritis, Hepatitis C, and multiple sclerosis, high costs may be preventing patients from accessing critical care and negatively impacting overall health outcomes.

One in four patients aged 60+ with a chronic condition have reported that they have stopped taking a medication because of the cost. It should never have to be an option, but it is, and as with HIV, skipping medication for other chronic diseases can be detrimental to health outcomes and result in even greater health care expenses down the road.

In the insulin price cap, CMS already has the blueprint for increasing access to medications for seniors in Medicare Part D. Now, to ensure more patients with potentially debilitating and life-threatening diseases can access critical care, the Trump administration must expand the Part D out-of-pocket cost cap to cover more conditions.

Carl Schmid is the executive director of the HIV+Hepatitis Policy Institute and co-chair of the Presidential Advisory Council of HIV/AIDS.

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