The pharmaceutical industry could see windfall profits from a little-noticed tweak to the insurance market tucked into the Trump administration鈥檚 draft executive order on drug prices, experts say.
The short, technical paragraph calls for the Internal Revenue Service to allow patients with high-deductible health plans to receive care for chronic diseases, including drugs, before meeting their deductibles.
This allowance, known as a 鈥渟afe harbor,鈥� could be welcome news for patients with chronic conditions like diabetes or asthma stuck with skimpy plans. For example, a diabetes patient could fill her prescription for insulin with just a copay, even if she hadn鈥檛 spent enough on medical bills for her insurance coverage to kick in. But in the long term, experts say, extending a safe harbor to chronic care would encourage more employers to adopt these skimpy plans, while shielding the pharmaceutical industry from pressure to lower drug costs.
鈥淚t鈥檚 hard to view this as anything but a substantial win for pharma,鈥� said Kim Monk, a partner and pharmaceutical expert at Capital Alpha Partners, which tracks laws and regulations for financial institutions.
High-deductible health plans have surged in the past five years.聽The U.S. Centers for Disease Control and Prevention estimates almost of patients ages 18-64 must pay $1,300 before receiving insurance coverage, and families must pay at least $2,600.聽And when faced with high drug prices, more of these patients skip filling prescriptions. Of the millions of insured Americans who struggle to pay their medical bills, skip filling a prescription due to cost according to a 2016 Kaiser Family Foundation poll. (Kaiser Health News is an editorially independent program of the foundation.)
These high-deductible health plans are likely to grow if the GOP health plan becomes law, the Congressional Budget Office.
But should the White House call on the IRS to offer a safe harbor for chronic disease medications, patients may visit the pharmacy more often despite the high deductibles.
鈥淵es, this provision could alleviate some of the pharmaceutical industry鈥檚 concerns about the increased cost-sharing patients with high-deductible plans could expect under the Republican health care bills,鈥� said Rachel Sachs, an associate professor of law at Washington University in St. Louis who studies the pharmaceutical industry. 鈥淎s the draft order notes, if high-deductible plan enrollees with chronic conditions can lower out-of-pocket costs for some of their medications, they will be more likely to adhere to their treatment regimens.鈥�
The language of the draft executive order could signal a significant expansion of drug coverage for the growing population with high-deductible plans, according to Stacie Dusetzina, assistant professor of pharmacy and public health at the University of North Carolina-Chapel Hill. Under the Affordable Care Act, preventive drugs were covered before the deductible was met, but the provision was 鈥渜uite narrowly defined and did not include medications that are used to prevent the progression of disease,鈥� Dusetzina said. 鈥淚nstead, it was more about preventing the disease altogether. In that way, the executive order could have a big impact on patient access to drugs.鈥�
But unlike coverage under Medicaid or under a plan with a higher actuarial value, the IRS would determine what care and medications are covered. It鈥檚 not yet clear whether the safe harbor would extend to essential HIV drugs, insulin or expensive drugs that treat rare diseases.
鈥淵ou鈥檙e asking the IRS to define something the IRS has never had to define before,鈥� said Monk.
The draft executive order explains that the expanded coverage is 鈥渇or the purpose of helping patients adhere to clinical regimes and thereby reducing the cost of care.鈥� For instance, a patient who can afford an inhaler is less likely to be admitted to the hospital for wheezing. But whether this compliance reduces the cost of care in the long term depends on treatment costs and drug costs,聽Sachs said.
The safe harbor for chronic care has been championed by the Smarter Health Care Coalition, a partnership linking industry heavyweights including America鈥檚 Health Insurance Plans (AHIP), the insurers鈥� lobbying group; the U.S. Chamber of Commerce; Novo Nordisk; and Pfizer.
The safe harbor will make high-deductible health plans more attractive to employers, according to Tracy Watts, a senior partner at benefits firm Mercer, which could prompt insurers to supply them. 鈥淪uch a change would go a long way toward encouraging more employers to offer [high-deductible] plans and would boost enrollment,鈥� Watts wrote in a blog post.
The White House has not issued an official executive order on drug prices yet. The draft order, first obtained by The , has been overshadowed by the political drama over the health bill on the Hill.
Major trade groups have largely avoided shedding political capital on the congressional health care fight 鈥� among the most conspicuously absent: PhRMA, the Biotechnology Innovation Organization and the Association for Accessible Medicines, the generic-medicines lobby.
Pharmaceutical companies would see a $2.7 billion annual tax break, but that money would be eclipsed by losses in revenue from Medicaid and Medicare, as well as the drop in demand for health care from the millions of newly uninsured, Moody鈥檚 .
PhRMA won鈥檛 yet say whether it supports the chronic-care safe harbor. 鈥淲e can鈥檛 speak to what the administration will do on this issue and don鈥檛 think it would be appropriate to speculate,鈥� said Holly Campbell, deputy vice president of public affairs at PhRMA.
KHN鈥檚 coverage of prescription drug development, costs and pricing is supported in part by the聽.