Push Congress to follow NC on co-pay assistance

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North Carolina's pay assistance initiative is worthy of national emulation, N.C. Rep. Carla Cunningham of Charlotte argues.

As the representative for the 106th District in the North Carolina House of Representatives, it is my responsibility to make life better for constituents in my district and across North Carolina.

As a healthcare professional for over 30 years,  my priority was to ensure patients got the care they needed. It is promising to know that modern medicine is allowing individuals plagued by chronic disorders an opportunity to live longer and have a better quality of life.

By way of innovation, there are new treatments for cancer, diabetes, cystic fibrosis, and other complex chronic illnesses. In my position, I hear so much about the toll of rising healthcare costs from my constituents, their families, and friends.

With all the innovation taken place recently, patients should be able to access the most effective lifesaving treatments we have on available. Patients are being left behind due to the soaring prices for specialty medicines at the expense of their health. Many people look for other ways to afford their medicines like coupons, vouchers, and other copay assistance programs.  

Co-pay assistance programs offered by various pharmaceutical manufacturers and non-profits have helped reduce out-of-pocket treatment expenses for so many who need it. These programs were intended to help people with savings and in turn put toward insurance deductibles.

With that, out-of-pocket maximums could be met, and insurance would cover the rest. This is no longer the case in many places.  

Pharmacy Benefit Managers (PBMs) and insurers have chosen to classify many new treatments as “non-essential” with no generic or alternative options available for most of them. In the fine print of many health plans, they have inserted a program called a co-pay accumulator that does not count the funds given by third parties for “non-essential” drugs toward a patient’s deductible.

This means that if a patient has a $500 copay, but an assistance program covers $400 of it, only $100 counts toward a patient’s deductible. PBMs are accepting money from the programs to support patients, but then they also force patients to pay thousands out of pocket to reach their maximums.  

Many patients do not know that their health plan has a co-pay accumulator and only find out when they are hit with unexpected bills well after they thought they reached their maximums. It is frustrating to know that this may deter many from lifesaving treatments.

Patients should have a chance to get the best treatments modern medicine can give to manage their illnesses.

In 2021, my colleagues and I in the N.C. House, and the N.C. Senate voted unanimously for the Medication Cost Transparency Act. This bill requires insurance companies to accept third-party copay assistance towards patient’s deductibles.

In September, Gov. Roy Cooper signed SB257 – making North Carolina just the seventh state to pass these protections against copay accumulator programs. Clearly, we need these protections on the federal level to enable patients access to affordable medications they need, especially patients managing chronic illnesses.  

It is good to know that similar legislation has been introduced in Congress with bipartisan support. H.R. 5801, the Help Ensure Lower Patient (HELP) Copays Act would have a tremendous impact on so many Americans facing illnesses like cancer, diabetes, multiple sclerosis, cystic fibrosis, and sickle cell.

I hope that members of Congress follow North Carolina’s example. They must pass the HELP Copays Act this year to protect patients and ensure everyone has access to life saving medication.  

Rep. Carla Cunningham represents Charlotte in the North Carolina House of Representatives. 

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