WASHINGTON — Consumers who use expensive brand-name prescription drugs when cheaper alternatives are available could face higher costs under a new policy being proposed by the Trump administration.
The proposal, to be published this week in the Federal Register, would apply to health insurance plans sold under the Affordable Care Act.
Health plans have annual limits on consumers’ out-of-pocket costs. Under the proposal, insurers would not have to count the full amount of a consumer’s co-payment for a brand-name drug toward the annual limit on cost-sharing. Insurers would have to count only the smaller amount that would be charged for a generic version of the drug.
For example, if a consumer filled a doctor’s prescription for a brand-name drug with a $25 co-payment, rather than using a generic medicine with a $5 co-payment, the consumer might get credit for only $5 in out-of-pocket spending. Consumers would have to spend more of their own money before reaching the annual limit on out-of-pocket costs.
In addition, insurers would not have to count the value of coupons and other financial assistance provided to consumers by drug manufacturers if generic alternatives were available. This change could significantly increase consumers’ out-of-pocket costs for some of the more expensive prescription drugs and has prompted protests from groups representing patients.
President Trump has repeatedly vowed to reduce drug prices and to lower out-of-pocket drug costs. But for some consumers, the latest proposal could have the opposite effect.
The proposal highlights a potential conflict between patients with a particular disease, who may benefit from the use of coupons, and other consumers more generally. Economists say that coupons can raise health care costs by encouraging people to use more expensive drugs.
“The availability of a coupon may cause physicians and beneficiaries to choose an expensive brand-name drug when a less expensive and equally effective generic or other alternative is available,” the Trump administration said in explaining its proposal. “When consumers are relieved of co-payment obligations, manufacturers are relieved of a market constraint on drug prices.”
Moreover, it said, “coupons can add significant long-term costs to the health care system that may outweigh the short-term benefits.”
But Bari Talente, an executive vice president of the National Multiple Sclerosis Society, said, “Many people with M.S. rely on co-pay assistance, even for generic medications.”
In the last few years, she said, generic versions of the drug Copaxone have become available, but even they have high prices. One of the generic medicines costs $60,000 to $65,000 a year, she said.
Carl E. Schmid II, the deputy executive director of the AIDS Institute, a public policy and advocacy organization, said the administration’s proposal could sharply increase out-of-pocket costs, so that a consumer who now pays virtually nothing might have to pay $3,500 a year or more for a drug to treat H.I.V.
“That increases the likelihood that people won’t pick up their drugs, won’t take their drugs,” Mr. Schmid said.
Leyla Mansour-Cole, the policy director of the Diabetes Patient Advocacy Coalition, a nonprofit group, said the Trump administration proposal “caused trepidation” for some patients.
“In theory, co-pay coupons could encourage people to take higher-priced drugs,” Ms. Mansour-Cole said. “In reality, people use them to get the medicines that their doctors prescribe, despite astronomically high deductibles.”
The administration is proposing several other changes that could increase costs for consumers.
Under the proposal, fewer people would qualify for federal subsidies, and those who qualify could be required to spend a larger share of their income on insurance premiums.
In addition, the proposal could lead to a small increase in out-of-pocket costs, which include co-payments and deductibles for doctors’ services and hospital care.
The changes would result from a new method of calculating inflation in health insurance prices — a factor used in computing the amount of premium subsidies and the annual limit on consumers’ out-of-pocket costs.
The Trump administration estimated that the changes would save the government $900 million annually in subsidies in 2020 and 2021 and $1 billion a year in 2022 and 2023. In addition, it predicted that 100,000 fewer people would have coverage through the insurance exchanges created under the Affordable Care Act.
The administration said that some of the 100,000 people might buy short-term insurance policies, which do not have to cover pre-existing conditions or provide all the benefits required by the health law. But, it said, most are “likely to become uninsured.”
Either way, the administration said, “these individuals will be bearing a larger share of the costs of their own health care consumption.”
The proposed rule may reduce federal spending and the need to collect taxes in the future, the administration said. “However,” it added, “the increased number of uninsured may increase federal and state uncompensated care costs.”
The administration estimated that premiums — after subsidies, in the form of tax credits — would be 1 percent higher as a result of its proposal.
The limit on out-of-pocket costs is already high; a consumer can be required to spend as much as $7,900 a year. Under the formula now in use, the limit would rise to $8,000 next year. Under the Trump administration proposal, it would increase to $8,200.
Administration officials said their proposal would more accurately measure insurance price inflation. But Democrats refused to accept that explanation, noting that Mr. Trump had tried to repeal the Affordable Care Act during his entire first year in office.
Senator Ron Wyden of Oregon, the senior Democrat on the Finance Committee, described the new proposed rule as “Trump’s latest attempt to sabotage health care.”
The Trump administration is also proposing a new requirement to increase the number of health insurance plans that omit coverage of abortion services.
Under the proposal, insurers that provide coverage of abortions would also have to offer at least one plan providing the same benefits but excluding coverage of abortions.
The administration said it was concerned that some people who wanted to buy insurance under the Affordable Care act refrained from doing so because they had religious or moral objections to abortion coverage. The administration acknowledged that some states like California, New York and Oregon generally required insurers to offer abortion coverage on the exchange, and it appears that the proposed federal requirement would not override such state laws.
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