Time to Stop Punishing the Chronically Ill: Why I Support Capping Out-of-Pocket Drug Costs

Care for Your Mind kicks off a new series on state-level issues of access to quality mental health care. This post focuses on activities in just one state, but advocacy around this topic is happening across the country.

Representative Laura Fine (Illinois 17th District)

I am a proud co-sponsor of legislation (IL HB 3605) that seeks to shield patients and their families from the exorbitant out-of-pocket drug co-payments increasingly being imposed by health insurers. This action is desperately needed in order to ensure that people living with serious illnesses can maintain affordable access to life-saving medications.

Under current practice, an insurer or pharmacy benefit manager may decide that a drug is too expensive and require patients to foot a significant share of the drug’s cost. It has become all too common for patients with chronic conditions to spend hundreds of dollars each month just to get the medication their doctor has prescribed.

With health insurance premiums taking a bigger chunk out of people’s wallets, many don’t have extra funds for unexpected out-of-pocket costs. This is why we now have so many people—sick people with serious and life-threatening diseases—facing the unbearable choice of paying for the medication they need, or going without and suffering the medical consequences.

And that’s not right.

The issue: higher co-pays for “specialty drugs”
Recently, many insurers have begun changing their prescription drug plans by placing certain drugs in a separate “specialty drug” category. Most insurers place any drug costing more than $600 a month into the specialty drug class. In most cases, the co-insurance on a specialty drug is much higher than the normal co-pay amount and can be as high as 40 percent of the total drug cost.

Complex, chronic conditions (like depression) are often treated with drugs from this category, and so people with chronic illness are disproportionately hit with steep out-of-pocket drug costs. In fact, households with a chronically ill family member spend 76 percent more on prescription medicines than other households.

Specialty drugs are vital to keeping disease in check and often mean the difference between disability and avoidable suffering. In many cases, there is no low-cost alternative, and physicians prescribe the drug because it is the most appropriate and medically sound choice for that patient.

Capping out-of-pocket drug costs can help people get the medication they need and end cost discrimination against people with chronic illness.

The solution
HB 3605 and its companion Senate Bill 1359 would cap out-of-pocket drug costs at $100 per prescription per month for silver, gold, and platinum health insurance plans, and $200 per prescription per month for bronze plans. The legislation affects plans purchased on the insurance marketplace and most employer-sponsored health plans.

If we fail to act on this issue, people who can’t afford their co-insurance may stop taking their medication, leading to unhealthier communities, unnecessary suffering, and a rise in overall medical and disability costs.

What you can do
People who share my concern about this issue should contact their state legislators to let them know this issue is important to their constituents. If you have a personal experience with soaring out-of-pocket drug costs, share your story. I can tell you that every email, call, and letter from a constituent is noted and they do make a difference.

With additional co-sponsors, public pressure, and support, we can put this discussion front and center, achieve the reform we need, and stop punishing people with chronic disease.

Laura Fine is serving her second full term as State Representative of the 17th district, representing Chicago’s northern suburbs. She serves on six committees in the Illinois House: Higher Education Appropriations, Environment, Insurance, Higher Education, Human Services, and Youth & Young Adults where she serves as Chairwoman. She is a former journalist and instructor at Northeastern Illinois University, and previously served as Northfield Township Clerk.

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