The Global Healthy Living Foundation (GHLF) today refreshed a free, interactive tool showing that state laws banning accumulator and maximizer clauses in health insurance policies have not increased the cost of health insurance. In nineteen states, to date, these laws protect patient assistance programs (PAPs) by requiring that the financial assistance given to patients count toward their co-pays, deductibles, and out-of-pocket (OOP) maximums. Set up as charitable programs by drug manufacturers, PAPs help patients afford expensive medications that might otherwise be out-of-reach based on the design of their health plan’s formulary and OOP payment requirements. Going as far back as 2014 and including the most recently available 2022-2023 data, the updated GHLF analysis and tool is for legislators, policymakers, and interested parties who value objective data to advocate for similar legislation in all states and at the national level.
“I was only ten years old the first time I went to the hospital with severe head pain, uncontrollable vomiting, and visual disturbances from a migraine attack, and I am still managing the disease 35 years later. When I finally found a specialty treatment that worked, it was expensive, and I relied on a patient assistance program to afford the medication that finally helped me feel better,” said New Braunfels, TX resident J.P. Summers, Patient Advocate, Community Outreach Manager, GHLF. “However, after I paid for my medicine using a PAP-funded card, expecting those funds to be applied to my deductible, they weren’t. Instead, my monthly co-pay jumped from $40 to around $350, or as much as a car payment. When my son’s medication was also slotted into an accumulator program, I had to make hard choices about which medications I could take home or not.”
All States Need to Protect Patients
Chronic disease patients are often the victims of accumulator and maximizer programs because they rely on expensive, brand-name medications for disease management when less expensive alternatives may not be effective or available to them. Therefore, legislation is needed in all 50 states because insurance and pharmacy benefit management (PBM) companies-instituted accumulator and maximizer programs shift the medication cost burden to individual patients.
Accumulator programs prohibit the value of a manufacturer’s co-pay or other support payments from counting toward patients’ annual deductible and OOP maximum obligations. Maximizers set patients’ OOP maximums equal to the maximum value of a manufacturer’s patient-assistance program, which is typically spread evenly throughout the benefit year. Maximizer programs also do not allow manufacturer’s co-pay or other support payments to count toward patients’ annual deductible and OOP maximum obligations.
“Insurance companies assert that restricting accumulator and maximizer programs will cause higher health insurance premiums for everyone, but that claim is false. Our analysis, which this year includes more data (n=13 states (2022); n=19 states (2023)), demonstrates no statistically significant change to premiums, nor is the rate of health insurance premiums rising in states with protective, patient-centered legislation enacted,” explained Dr. Robert Popovian, PharmD, MS, Chief Science Policy Officer, Global Healthy Living Foundation.
Dr. Popovian added, “Insurance contracts are complex, and an individual or family may not even realize that an accumulator or maximizer program is written into the fine print until it is too late and they are told at the pharmacy that they still owe their deductible or co-insurance for that prescription in the middle of a plan year, despite using up their PAP-supplied funds. It’s not reasonable that patients are paying more than their fair share. We encourage legislators and other advocates who develop state and federal health policy to use our tool to fight for patient-protective laws nationwide.”
Notably, the GHLF tool also underwent a Usability Redesign, making it easier to see insurance cost changes by state since 2014 and the average change for states that have (blue) or have not (orange) protected patient assistance programs.
In the U.S., over 90 percent of prescribed medications are available as generics. Most of the rest are specialty, brand-name medications, used disproportionately by the chronic disease community without generic or biosimilar options.
Calculating Health Insurance Premium Fluctuations
Using raw data from the HIX compare + website (Robert Wood Johnson Foundation), which provides data for most health insurance policies available through the Affordable Care Act (ACA) Healthcare Marketplace, GHLF created two separate databases to calculate average health insurance premiums for individual purchasers and small group purchasers. For plans available to individual purchasers, each state’s average premium for each insurance metal tier (bronze, silver, gold, platinum) for every year from 2014 to 2023 was calculated and recorded for an individual adult and for a family of two adults and two dependents. For plans available to small-group purchasers, the same averages were recorded for 2014 to 2022 (as 2023 is not yet available). Averages were calculated as the sum of the health insurance premiums for all plans in a specific tier in a particular state divided by the number of available health plans for that tier in that state.
The second variable analyzed was the introduction of legislation protecting patient assistance programs by prohibiting accumulators and/or maximizers. Changes in the magnitude of the percent rate change in average premiums were compared as raw percentages and analyzed with repeated ANOVA measures to evaluate whether premium rate changes were significantly different from one year to the next. The analysis shows that across all “metal tiers,” there has been no statistically significant difference in the rates of health insurance premium increases upon passage or implementation of legislation protecting patient assistance programs by prohibiting accumulator and/or maximizer policies.
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