On February 12, 2015, Representatives from Harvard Law School’s Center for Health Law and Policy Innovation (CHLPI) presented to the members of the Presidential Advisory Council on HIV/AIDS (PACHA) during a two-day long meeting on progress and challenges to the council’s charter of advancing the prevention and cure of HIV and AIDS and ensuring that those infected with HIV or AIDS are provided with quality care.
Carmel Shachar, Staff Attorney for CHLPI, presented “2015 Healthcare Marketplace & the HIV Community: A Review of Essential Health Benefits and Provider Networks” and highlighted findings from CHLPI’s Speak Up! project and other initiatives on discriminatory practices by insurance providers against individuals living with HIV/AIDS. Many plans on the health insurance marketplace throughout the nation are placing HIV medications on formulary tiers with very high levels of cost-sharing, requiring individuals to pay for a very significant portion of health care costs not covered by their insurance plan.
Instances of adverse tiering and prohibitive cost-sharing are more prevalent in the South; CHLPI’s review of the qualified health plans (QHPs) offered in five southern states in 2014-2015 found that more than half of the plans required co-insurance of at least 30% for HIV medications. “These biased practices translate to an extreme and unsustainable financial burden inequitably imposed on those least able to bear it. Studies published in the New England Journal of Medicine have found that an individual living with HIV who is enrolled in a plan with adverse tiering will spend $3,000 more per year than an individual enrolled in a different plan,” Shachar explained to the meeting’s attendees.
CHLPI’s director and clinical professor of law, Robert Greenwald, said “When we see instances of copays going from $60 a month to $760 a month for medications specifically to treat chronic illness, as reported to us in the Speak Up! project, we can’t deny that there are problems with the system that need to be addressed on a wide scale. There are some insurance providers doing the right thing, but when it comes to access to life-sustaining medicine, some providers aren’t doing enough.”
Based on CHLPI’s research and findings, Shachar presented recommendations to PACHA on how to address these alarming trends through law and policy changes. They include amending the Essential Health Benefits (EHB) rule to require coverage of specialty drugs widely accepted in treatment guidelines or best practices, and prohibiting excessive coinsurance for specialty drugs. CHLPI is also calling for all Marketplace plans to provide complete, accurate, and accessible formulary information in a standard format to increase transparency and understanding for plan participants.