The EACH/PIC Coalition submitted a group letter signed by 38 organizations to Minority Staff for the Senate Finance Committee in response to the request for information on Health Coverage that Works for Everyone.
The letter stated:
As policymakers consider reforms to make insurance more affordable and effective, we encourage the committee to focus not only on whether individuals have coverage, but whether that coverage provides affordable, predictable, and reliable access to the care they need.
EACH/PIC conducted a comprehensive Patient Experience Survey to better understand how patients and caregivers experience prescription drug affordability. The survey was designed to capture the context often missing from traditional affordability assessments, including how insurance coverage, out-of-pocket costs, financial assistance, and other healthcare expenses affect patients’ ability to access and remain on prescribed treatment.
Importantly, the results demonstrate that insurance coverage, or the lack of it, was among the most frequently cited reasons patients experienced affordability challenges. Respondents described insurance-related challenges as significant barriers to accessing and remaining on needed medications.
Among patients who stopped taking a medication, 95 percent cited insurance-related challenges, including formulary changes, accumulators, step therapy, non-medical switching, loss of coverage, and high deductibles. Similarly, among patients who reported never starting a prescribed medication, 72 percent cited insurance-related challenges, including coverage denials and high out-of-pocket costs despite having insurance.
Make Patient Costs More Manageable and Predictable
Patients managing chronic conditions often face healthcare expenses that are unpredictable and can vary significantly over time. Changes in deductibles, premiums, cost-sharing requirements, or insurance coverage can cause sudden shifts in out-of-pocket costs, creating financial uncertainty and contributing to hardship even for patients who previously considered their care affordable.
Congress should consider policies that directly limit patients’ financial exposure, including lower deductibles, reasonable annual out-of-pocket maximums, limits on premium increases tied to inflation, and other protections against sudden or unmanageable costs. Policymakers should also expand opportunities for patients to smooth healthcare costs throughout the year rather than requiring significant expenses to be paid early in a coverage period. These approaches can make expenses more predictable and help patients maintain continuity of care.
Protect and Expand Patient Financial Assistance
Financial assistance programs can provide an important safeguard for patients who would otherwise struggle to afford prescribed treatment. Congress should protect and expand access to Patient Assistance Programs for individuals with low incomes, disabilities, or without insurance and support awareness of manufacturer copay assistance available to commercially insured patients. Application and enrollment processes should also be simplified so that eligible patients can more readily access available support.
Improve Transparency and Align Incentives with Patients
Finally, reforms should address incentives within the healthcare marketplace that can affect patient costs and access. This includes prohibiting spread pricing, replacing percentage-based PBM compensation with flat-fee service models, ensuring negotiated rebates and discounts are passed through to patients, and increasing transparency around PBM contracts, rebate flows, and formulary design.