Op-Ed | Why Congress must pass a ban on Copay Accumulators

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As a New York State Representative and a nurse, I have seen firsthand the devastating impact of rising healthcare costs on the health and financial stability of families.

I was proud to cosponsor legislation signed by Governor Hochul in December to ban copay adjustment programs, one of the more recent attempts by the insurance industry to enrich themselves at the expense of sick patients. But despite our state’s new law, we still need Congress to pass similar legislation to make sure this practice doesn’t continue to torment New York families.

Copay accumulators or maximizers are a scheme drawn up by health insurance companies and pharmacy benefit managers to make money off chronically ill patients.  How do they accomplish this? By twisting the language introduced in the Affordable Care Act (ACA) that is supposed to ensure patients have access to lifesaving medicines and mischaracterizing newer specialty drugs as “non-essential health benefits.” 

Under the ACA, drugs labeled non-essential must still be covered, but insurers don’t have to accept any financial assistance towards the treatment.  Since close to 80% of the treatments subject to copay accumulator language don’t have a generic or even brand alternative, getting assistance from charities, drug manufacturers or non-profits are the only ways for patients and their families to afford their prescribed medications.

Families should not have to choose between paying for essential treatments or putting food on the table. Copay accumulators only add to the financial burden that many families already face and can force patients to forego essential treatments. This not only puts their health at risk but can lead to costly hospitalizations and long-term health consequences.

As a nurse, I have seen the positive impact that access to healthcare can have on the health and wellbeing of patients and their families. 

Chronic diseases are difficult to manage even in the best of circumstances because they require constant care and can be life-limiting.  Some like sickle cell anemia, hemophilia and cystic fibrosis affect people since birth and having access to the right treatment can add decades to their life expectancy. The ACA was supposed to solve the problem of companies prioritizing profits over patients, but copay accumulators have threatened the progress made, putting us right back where we were more than a decade ago.

We need Congress to act by closing this loophole to protect the health and financial stability of families. The proposed ban on copay accumulators will ensure that patients receive the treatments they need, without facing undue financial burden. This is a matter of basic fairness and compassion.

I thank my Congresswoman Yvette Clarke, who is a cosponsor of H.R. 5801, the Help Ensure Lower Patient (HELP) Copays Act, and I look forward to supporting her efforts to move this bill and put the health and wellbeing of families first.