Yesterday, Margot Sanger-Katz of The New York Times reported on a recent survey of the problems Americans face with medical bills. The survey, conducted by The New York Times and the Kaiser Family Foundation, shows a cascade of financial troubles due to many individuals and households paying substantial medical bills. In the survey, 20 percent of people under age 65 with health insurance reported having problems paying their medical bills in the last year, compared with 53 percent of people without health insurance reporting such problems.
Despite the strengths of the ACA, paying medical bills is hard for many people living with HIV, including those with insurance. One common problem is that people living with HIV often have to pay thousands of dollars upfront in deductibles rather than have the cost of their medication spread throughout the year. For those living on tight budgets, this upfront cost means that some people delay treatment until they can pay, use up all or most of their savings, or borrow money. It also affects people’s daily lives, including their ability to pay for housing, food, and childcare.
People living with HIV also have financial troubles when insurance premiums and co-payments add up to make HIV care unaffordable or when big medical bills are not covered by insurance. The ACA’s annual cap on out-of-pocket spending does not count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing, or spending for non-essential health benefits. As a result, insured patients can struggle to pay their bills.
This is all the more true for people living with HIV in “narrow network” plans, i.e., health insurance plans that place limits on the doctors and hospitals available, and in “adverse tiering” plans, i.e., health insurance plans placing classes of drugs on tiers with high co-payment and co-insurance levels. When plan networks have too few specialty HIV care providers, they have the effect of denying lifesaving care. An alternative consequence is financial hardship for those who can only get appointments with non-network providers. Likewise, when health plans engage in adverse tiering by putting HIV drugs on the top tier of formularies, people living with HIV are forced to pay higher medical costs.
Much work still needs to be done to make access to affordable care a reality. Change never comes fast enough, but we must continue efforts to build upon the successes of the ACA. I believe that the Ryan White program is likely to act as the fulcrum of such efforts related to HIV and may serve as a model for making medical and support services affordable, accessible, and effective for all.
The views reflected in this expert column are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.