Blog (October 2012)
Georgians for a Healthy Future is a proud partner in the Specialty Tiers Coalition of Georgia, a group of consumer and patient advocates committed to ensuring affordable access to medications for patients with rare, chronic conditions. Earlier this month, the coalition hosted an educational forum at Emory University in Atlanta to raise awareness among policymakers and consumers about the growing trend of specialty tiers and the related risks to patients and consumers.
Specialty drugs are typically breakthrough prescription drugs that are used to treat complex, chronic health conditions such as cancer, multiple sclerosis, rheumatoid arthritis, hemophilia, and HIV/AIDS. Traditionally, insurance plans cover prescription drugs on a 3-tiered drug formulary (Tier One: generic drugs; a typical co-pay is around $10; Tier Two: preferred brand name drugs; a typical co-pay is around $30; Tier Three: non-preferred brand drugs; a typical co-pay is around $50). Specialty tiers, also known as Tier IV, V, or VI, add an additional structure for specialty medications — cost sharing known as “co-insurance” — where the patient pays 20-35% of the cost of the medication, rather than a fixed, predictable co-payment. Unfortunately, there is no limit on what a beneficiary may be required to pay for therapies relegated to specialty tiers.
The trend towards specialty tiers shifts costs to patients and places needed treatment out of reach for too many patients who are paying health insurance premiums to get the medical care they need. Specialty tiers can result in drug costs well into the thousands of dollars per month for patients, increasing the likelihood that patients will go without needed treatment. In fact, a recent study found that one in four patients with an out-of-pocket prescription cost of $500 or more failed to fill their prescriptions. This indicates patients with insurance are having to choose between needed medications and everyday living expenses.
The Specialty Tiers Coalition will be active in the upcoming 2013 Legislative Session to grow awareness about this issue, and advocate for patient protections. Georgians for a Healthy Future and the coalition are currently serving as a community partner to the Health Legislation & Advocacy course at Georgia State University’s College of Law. Through this partnership, law students are providing research assistance and helping craft potential legislation to ensure adequate patient protections.
Earlier this year, Governor Deal signed into law House Bill 1166 to restore child-only health insurance plans to the Georgia marketplace. The legislation was sponsored by Representative Atwood and supported by a broad coalition of consumer health advocates, health care industry stakeholders, and legislators, including Georgians for a Healthy Future. The law goes into effect on January 1, 2013, and will make standalone insurance policies for children available through an open enrollment period in January or in the event of a qualifying event throughout the year. The Georgia Department of Insurance is currently preparing the draft regulation, after which there will be a public comment period with the final regulation expected in December.
Several states around the country have taken similar action to make these plans available for children, and earlier this month the Commonwealth Fund issued a report examining legislative and regulatory efforts around the country during 2010 and 2011 and found that, in states that had taken action during those years, child-only coverage is now available in nearly all of those states. Since Georgia’s legislation was passed in 2012 and has not yet gone into effect it was not included in the analysis; however, the authors interviewed officials and advocates in Georgia and noted that legislation had been signed into law in 2012. Kaiser Health News also reported on the story last week. That article is available here. The study is available here.
Health exchanges are a central feature of the Affordable Care Act and are intended to provide meaningful and affordable health insurance options for individuals and families who don’t have access to health insurance at work. The exchange, or marketplace, will be a place where consumers can shop for private health insurance plans utilizing decision tools and accessing tax credits to make the plans affordable. By 2014, these marketplaces will be up and running in every state, with some states operating their own exchange marketplaces, some states partnering with the U.S. Department of Health and Human Services on a “state partnership exchange,” and some states deferring to a federally facilitated exchange.
States planning to move forward with their own state-based exchanges must submit a blueprint by November 16th of this year. Georgia is not expected to be ready for a state-based exchange, as reported in the Atlanta Journal Constitution last week, and thus a default to a federally facilitated exchange is likely in Georgia.
Ensuring that a health insurance exchange works for Georgia consumers is a key priority for Georgians for a Healthy Future, whether it is a state-based exchange, partnership exchange, or federally facilitated exchange. Regardless of who is administering the exchange on the back end, we must make sure it works for consumers on the front end. To that end, Georgians for a Healthy Future remains engaged in this important issue on behalf of health care consumers. Our Executive Director served on the Governor’s Health Insurance Advisory Committee in 2011, which studied options for Georgia, and submitted a minority report advocating for Georgia to move forward with planning for a state-based exchange despite the full committee’s recommendations against doing so; Georgians for a Healthy Future released a well-received policy brief in August 2011 making policy recommendations for a Georgia exchange; and our staff and coalition partners have been active in discussions with federal officials, along with consumer health advocates from around the country, about how to make sure federally facilitated exchanges are responsive to the needs of consumers within the states.
More information about the exchange blueprint submission process is available here; a summary of Georgia’s status on exchange planning is available here; and all archived materials from Governor Deal’s health insurance exchange advisory committee are available here.
Today, Georgians for a Healthy Future’s Executive Director Cindy Zeldin presented to the annual Georgia Women’s Assembly, organized by Georgia Women for a Change, on the Medicaid expansion and why it matters for women. We know that covering Georgia’s uninsured by implementing the Medicaid expansion will improve access to care, provide resources for the state’s health care delivery system, and bolster Georgia’s economy. But what about women in particular? Medicaid today provides a lifeline for many women, serving as a source of coverage for low and moderate-income pregnant women, low-income mothers, and low-income women diagnosed with breast or cervical cancer. Yet too many women are left out. Expanding Medicaid will extend that lifeline to more low-income moms and low-income women without children who aren’t eligible for Medicaid today. More than two-thirds of uninsured women report difficulty accessing care, which tells us that too many women who want and need an entry point to the health care system to meet basic medical needs cannot get it today. The Medicaid expansion will help open that door. Another reason to Cover Georgia!
To download Cindy Zeldin’s power point presentation from the Georgia Women’s Assembly, click here.
More than 26,000 Americans die every year because they lack health insurance. Right here in Georgia, an estimated 1,000+ people died in 2010 because they didn’t have health insurance, among the most in the nation. People who are uninsured are less likely to have a usual source of care, often go without screenings and preventive care, and delay or forgo needed care. This tragic reality has persisted for too long. Please join our friends at HealthSTAT in a candlelight vigil on Wednesday, October 24th at 7pm on the steps of the Georgia state capitol in memory of those who have lost their lives because they could not afford or did not have access to health insurance. Then, let’s redirect our energy towards covering all Georgians.
Georgia policymakers are currently weighing the opportunity to cover an estimated 650,000 uninsured Georgians through an expansion of the Medicaid program. Under the Affordable Care Act, states can create a new category of eligibility for Medicaid to cover low-income individuals and families, financed almost entirely with federal dollars. Implementing this expansion is the only viable way to cover Georgia’s low-income uninsured, and it will pump resources into our state’s health care delivery system. We can’t miss this opportunity to improve access to health care and to strengthen Georgia’s health care economy, but we need your voice to make it happen.
Health care consumer and patient advocacy groups, providers, stakeholders, and community groups are coming together under the Cover Georgia umbrella to show support for expanding Medicaid, and we invite you to join us. If you are interested in getting involved in this discussion, please contact Amanda Ptashkin.
In November, the Cover Georgia campaign will unveil a website full of resources to help you better understand and advocate for the Medicaid expansion with policymakers and in your community. In the meantime, please visit Families USA’s Medicaid Expansion Center, with links to studies and reports about the value of Medicaid, and the Center on Budget and Policy Priorities’ Tool Kit for State Advocates on the Medicaid expansion.
Gaining health care coverage through Medicaid improves access to care, reduces financial strain, and saves lives. Those are some of the takeaways from an engaging and enlightening forum hosted this morning by the Georgia Budget and Policy Institute. The featured speakers, Dr. Heidi Allen and Dr. Benjamin Sommers, presented research findings on the impact of gaining Medicaid coverage on health status and participated in a panel discussion moderated by GBPI’s Tim Sweeney and Georgians for a Healthy Future’s Cindy Zeldin about the implications for Georgia as our state’s policymakers weigh the costs and benefits of covering the uninsured in Georgia through an expansion of Medicaid. The audience was live tweeting the event under #covergeorgia, allowing those who missed to hear what the audience was saying as it was happening. You can read their tweets here. Georgia Health News also reported on the event (story here). To get involved with Cover Georgia, the emerging educational and advocacy effort to make the case for expanding Medicaid to cover Georgia’s uninsured, please e-mail Georgians for a Healthy Future’s Outreach & Advocacy Director, Amanda Ptashkin.
Here are some photos from today’s event.
Georgia consumers purchasing health insurance deserve the peace of mind that comes from knowing that they are purchasing a quality plan that meets basic standards and that will provide adequate protection in the event they get sick. That is why Georgians for a Healthy Future is monitoring the essential health benefits selection process. As part of the Affordable Care Act (ACA), beginning in 2014 all health insurance plans sold in the private individual and small group markets must include a minimum package of benefits to ensure that all consumers purchasing health insurance have access to comprehensive health care services.
In a process outlined late last year by the U.S. Department of Health and Human Services, states were instructed to choose a benchmark plan and supplement it to fill any gaps (the essential health benefits package must, under federal law, include items and services within ten broad categories, described here). Georgia chose the default option, the largest small group plan sold within the state, as our state’s benchmark plan. According to the Georgia Department of Insurance, the U.S. Department of Health and Human Services (HHS) will review and supplement the plan. You can read more about this issue and Georgia’s decision to default to federal officials on the decision in Georgia Health News here.
Later this fall, HHS is expected to issue a notice of proposed rule-making listing each state’s minimum essential health benefits package. The National Academy for State Health Policy is also tracking all states’ progress on essential health benefits. You can view their latest chart here.