Just having health insurance is no longer enough to ensure access to affordable healthcare.
Today, millions of people covered by commercial health plans, the Affordable Care Act, or Medicare still find themselves unable to afford the out-of-pocket costs required to start and stay on their medical treatment.
The PAN Foundation is uniquely positioned to recommend strategies that improve healthcare access and affordability for those most impacted by rising out-of-pocket costs.
Since 2004, the PAN Foundation has provided a critical safety net for nearly one million underinsured people with life-threatening, chronic, and rare diseases who would otherwise have gone without treatment.
Our policy recommendations
Each of the following recommendations prioritizes patients’ needs in our complex healthcare system and focuses on improving healthcare access and affordability for all people living with a serious chronic illness.
Areas of focus
Limit out-of-pocket costs for all patients
The administration, Congress, and public and private insurers should set policies that ensure that out-of-pocket costs for prescription medications are affordable and do not prevent patients—especially those with lower or fixed incomes—from starting and staying on medically necessary treatments.
Recognize the value of charitable patient assistance
Until policies ensure our nation’s most vulnerable patients can access medically necessary treatments, the administration and Congress must recognize that charitable assistance programs and foundations play a critical role in the healthcare safety net.
Cap out-of-pocket costs
Congress and the Centers for Medicare and Medicaid Services should set a limit on the amount Medicare beneficiaries must spend out-of-pocket on prescription drugs.
Smooth out-of-pocket costs throughout the year
Congress, insurers, and other stakeholders should modify the structure of public and private insurance plans to spread out-of-pocket costs for prescription medications evenly over the course of the year so that patients can access and remain on the treatments they need. This strategy is also commonly referred to as “smoothing.”
Include specialty medications on a fixed co-pay tier
Public and private insurers should place at least one highly effective, innovative medication on a fixed co-pay formulary tier for all conditions to increase access and treatment adherence.
Modernize Medicare Part D
The administration and Congress should modernize the Medicare Part D benefit design to reduce the financial burden on beneficiaries.
Modernize the Medicare Part D Low-Income Subsidy (LIS) Program
Congress should modernize the Extra Help program to help more patients, eliminate cost-sharing for generic drugs, and ensure all eligible beneficiaries enroll in the program.
Eliminate vaccine co-pays under Medicare Part D
Congress, the Centers for Medicare and Medicaid Services, and insurers should eliminate vaccine co-pays in the Medicare Part D program in order to make them accessible to all beneficiaries.
Expand Medicare to include dental, hearing, and vision
Congress should expand Medicare to include and ensure adequate dental, hearing, and vision coverage and minimize out-of-pocket spending for these services.
Reduce high upfront insurance deductibles
Insurers must mitigate the impact that high upfront deductibles in commercial health insurance plans have on patients’ ability to start and stay on their prescription medications.
Prohibit co-pay accumulators
Congress, the Centers for Medicare and Medicaid Services (CMS), and insurers should prohibit harmful co-pay accumulator programs and allow commercially-insured patients to use manufacturer co-pay cards and coupons to meet their deductibles.
Adopt value-based insurance designs
Under a value-based insurance design approach, treatments that provide high clinical value have low or no patient cost-sharing to increase patient access, ensuring more affordable care for patients.
Develop policy that considers total out-of-pocket costs
While reducing out-of-pocket expenses for prescription therapies is an important goal, it is equally vital that patients have affordable access to the other healthcare services.
Address social determinants of health in insurance policies
Socioeconomic factors like economic stability, education, healthcare access and quality, neighborhood and environment, and social and community contex
Limit out-of-pocket costs for all patients
The administration, Congress, and public and private insurers should set policies that ensure that out-of-pocket costs for prescription medications are affordable and do not prevent patients—especially those with lower or fixed incomes—from starting and staying on medically necessary treatments.
Recognize the value of charitable patient assistance
Until policies ensure our nation’s most vulnerable patients can access medically necessary treatments, the administration and Congress must recognize that charitable assistance programs and foundations play a critical role in the healthcare safety net.
Cap out-of-pocket costs
Congress and the Centers for Medicare and Medicaid Services should set a limit on the amount Medicare beneficiaries must spend out-of-pocket on prescription drugs.
Smooth out-of-pocket costs throughout the year
Congress, insurers, and other stakeholders should modify the structure of public and private insurance plans to spread out-of-pocket costs for prescription medications evenly over the course of the year so that patients can access and remain on the treatments they need. This strategy is also commonly referred to as “smoothing.”
Include specialty medications on a fixed co-pay tier
Public and private insurers should place at least one highly effective, innovative medication on a fixed co-pay formulary tier for all conditions to increase access and treatment adherence.
Modernize Medicare Part D
The administration and Congress should modernize the Medicare Part D benefit design to reduce the financial burden on beneficiaries.
Modernize the Medicare Part D Low-Income Subsidy (LIS) Program
Congress should modernize the Extra Help program to help more patients, eliminate cost-sharing for generic drugs, and ensure all eligible beneficiaries enroll in the program.
Eliminate vaccine co-pays under Medicare Part D
Congress, the Centers for Medicare and Medicaid Services, and insurers should eliminate vaccine co-pays in the Medicare Part D program in order to make them accessible to all beneficiaries.
Expand Medicare to include dental, hearing, and vision
Congress should expand Medicare to include and ensure adequate dental, hearing, and vision coverage and minimize out-of-pocket spending for these services.
Reduce high upfront insurance deductibles
Insurers must mitigate the impact that high upfront deductibles in commercial health insurance plans have on patients’ ability to start and stay on their prescription medications.
Prohibit co-pay accumulators
Congress, the Centers for Medicare and Medicaid Services (CMS), and insurers should prohibit harmful co-pay accumulator programs and allow commercially-insured patients to use manufacturer co-pay cards and coupons to meet their deductibles.
Adopt value-based insurance designs
Under a value-based insurance design approach, treatments that provide high clinical value have low or no patient cost-sharing to increase patient access, ensuring more affordable care for patients.
Develop policy that considers total out-of-pocket costs
While reducing out-of-pocket expenses for prescription therapies is an important goal, it is equally vital that patients have affordable access to the other healthcare services.
Address social determinants of health in insurance policies
Socioeconomic factors like economic stability, education, healthcare access and quality, neighborhood and environment, and social and community contex
Limit out-of-pocket costs for all patients
The administration, Congress, and public and private insurers should set policies that ensure that out-of-pocket costs for prescription medications are affordable and do not prevent patients—especially those with lower or fixed incomes—from starting and staying on medically necessary treatments.
Recognize the value of charitable patient assistance
Until policies ensure our nation’s most vulnerable patients can access medically necessary treatments, the administration and Congress must recognize that charitable assistance programs and foundations play a critical role in the healthcare safety net.
Cap out-of-pocket costs
Congress and the Centers for Medicare and Medicaid Services should set a limit on the amount Medicare beneficiaries must spend out-of-pocket on prescription drugs.
Smooth out-of-pocket costs throughout the year
Congress, insurers, and other stakeholders should modify the structure of public and private insurance plans to spread out-of-pocket costs for prescription medications evenly over the course of the year so that patients can access and remain on the treatments they need. This strategy is also commonly referred to as “smoothing.”
Include specialty medications on a fixed co-pay tier
Public and private insurers should place at least one highly effective, innovative medication on a fixed co-pay formulary tier for all conditions to increase access and treatment adherence.
Modernize Medicare Part D
The administration and Congress should modernize the Medicare Part D benefit design to reduce the financial burden on beneficiaries.
Modernize the Medicare Part D Low-Income Subsidy (LIS) Program
Congress should modernize the Extra Help program to help more patients, eliminate cost-sharing for generic drugs, and ensure all eligible beneficiaries enroll in the program.
Eliminate vaccine co-pays under Medicare Part D
Congress, the Centers for Medicare and Medicaid Services, and insurers should eliminate vaccine co-pays in the Medicare Part D program in order to make them accessible to all beneficiaries.
Expand Medicare to include dental, hearing, and vision
Congress should expand Medicare to include and ensure adequate dental, hearing, and vision coverage and minimize out-of-pocket spending for these services.
Reduce high upfront insurance deductibles
Insurers must mitigate the impact that high upfront deductibles in commercial health insurance plans have on patients’ ability to start and stay on their prescription medications.
Prohibit co-pay accumulators
Congress, the Centers for Medicare and Medicaid Services (CMS), and insurers should prohibit harmful co-pay accumulator programs and allow commercially-insured patients to use manufacturer co-pay cards and coupons to meet their deductibles.
Adopt value-based insurance designs
Under a value-based insurance design approach, treatments that provide high clinical value have low or no patient cost-sharing to increase patient access, ensuring more affordable care for patients.
Develop policy that considers total out-of-pocket costs
While reducing out-of-pocket expenses for prescription therapies is an important goal, it is equally vital that patients have affordable access to the other healthcare services.
Address social determinants of health in insurance policies
Socioeconomic factors like economic stability, education, healthcare access and quality, neighborhood and environment, and social and community contex
When I was diagnosed with Parkinson’s disease, each new prescription would eat through our savings until there was nothing left.”
Lynn Estep, Indiana Living with Parkinson’s disease
TAKE ACTION
Ask for a limit on what you pay out-of-pocket for prescription medications
Write Congress