California legislators must prioritize patients over profits

OPINION – Trying to manage a chronic disease can be overwhelming. Getting access to medications to treat the disease should not be. No one should have to choose between putting food on the table or getting life-saving medication to manage their health.

Increasingly, patients are experiencing challenges accessing medications prescribed by their physician due to a health insurer practice called “copay accumulators.” People I treat who are living with serious, complex chronic illnesses such as osteoarthritis, rheumatoid arthritis (RA), and lupus, as well as patients with HIV, cancer, autoimmune diseases, multiple sclerosis and hemophilia often rely on specialty medications to manage their conditions and maintain their health for which there is no generic alternative drug available.. As a result, many patients living with serious chronic conditions have turned to patient copay assistance programs run by charitable organizations or pharmaceutical manufacturers for help paying copayments and coinsurance for specialty drugs since they have difficulty paying their health plan annual cost-sharing obligation on their own.

Millions of Americans endure long and expensive medical journeys to get the medications that best treat their needs. Copay accumulator adjustment policies allow insurers and pharmacy benefit managers (PBMs) to collect copayments on an enrollee’s behalf without counting those payments toward the enrollee’s annual deductible or out-of-pocket limit. These policies undermine access to life-saving prescription drugs for people living with serious, complex, chronic illnesses. According to the AIDS Institute 2024 report, California received a C because 5 out of 12 plans have copay accumulator policies.

In the past, insurers counted copay assistance toward the patient’s deductible and maximum out-of-pocket costs. For example, if a patient with a $2,000 annual deductible received a bill for $1,500 for their medication, the copay assistance program might pay the entire amount of $1,500 and the remaining annual deductible for the patient would be reduced to $500. But now an increasing number of insurers are implementing copay accumulators, diverting that assistance to themselves instead of patients. In this case, the copay assistance program would pay $1,500 but the patient responsibility for the deductible would remain $2,000. Under the “copay accumulator” practice, the insurer is collecting from both the copay program and the patient. They are getting paid twice.

This practice of double-dipping via copay accumulators is why California lawmakers should pass AB 2180 that would ensure that copay assistance is counted toward meeting the patient’s out-of-pocket costs.

If a medication is perceived as expensive and unaffordable, patients may decide not to take it. Copay assistance allows patients access to medications as prescribed by their doctor without worrying about the financial impact of treatment. Treatment adherence reduces health care costs in the long run. When patients do not adhere to their medications, they may have symptom flares, relapses, or hospitalization; this can lead to a long-term increase in disability and an overall increase to the cost of care.

Medication decisions should be between the physician and the patient, not dictated by an insurance company. Removing the benefit of patient assistance programs would make many medications unaffordable and drive patients to less effective products and treatments because many patients simply cannot afford to pay their maximum out-of-pocket cost-sharing obligation in full year-after-year.

Recently, Oregon became the 20th state, along with Washington, D.C., and Puerto Rico, that have already passed laws to ban copay accumulator practices. California lawmakers should prioritize patients over insurer profits and pass AB 2180. In doing so, they will secure more just and equitable health care delivery for their most vulnerable constituents.

Dr. Samy Metyas, MD. MSc, FACR, FACP, is a rheumatologist and Medical Director of the Covina Arthritis Clinic in Covina, California and is the President of the California Rheumatology Alliance.