Here’s another way to view how insurance and PBMs fit into the chain between a patient and a drug company. Notice how this No Patient Left Behind (NPLB) graphic shows that patients pay both premiums to their insurance company AND out-of-pockets at the pharmacy counter via their deductibles and copays. But what happens if someone isn’t paying premiums because they don’t have insurance?
These patients lose out on the discounts negotiated by PBMs for insurance plans and can be on the hook to pay list price, fully out of pocket. This is yet another problematic result of PBM incentives.
Health insurance isn’t something you can usually purchase at the drop of a hat, and disease and injury have unpredictable timing. The Affordable Care Act (ACA) made it illegal to deny a patient insurance based on preexisting conditions, but open enrollment periods still limits when you can sign up for a new insurance plan (though there are exceptions for loss of employment, change in marital status, having or adopting a baby, and moving residence). Still, there could be other obstacles in your way (income, immigration status, etc). So if you fall ill or hurt yourself and you don’t have insurance, you might not be able to get insurance right away.
If a patient finds themselves needing an expensive treatment, but they don’t have insurance, there are a few places they can turn. It’s an important point that these options are paid for by others, which means they actually function as a kind of insurance:
- Patient Assistance Programs (PAPs): Many drug makers and hospitals offer PAPs that include free or discounted services, sometimes set up through a payment plan. If 20% of patients need a free drug, then the cost of that drug is baked into the price that is paid by insurance for the 80% of patients who are covered (which means that it’s cost is borne by everyone who pays insurance premiums). PAPs tend to only be offered to those who meet certain economic criteria, and they tend to be tricky to navigate. Still, PAPs offer an important alternative for those who have no other way to pay their medical or pharmaceutical bills.
[OPTIONAL] The PAN foundation helps people find a program that is right for them. Drug makers’ PAPs can often assist insured people saddled with high out-of-pocket expenses.
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Emergency Rooms: The EMTALA (Emergency Medical Treatment and Active Labor Act) is a federal law that mandates that any hospital with an emergency department must stabilize and provide necessary treatment to any patient experiencing a medical emergency, regardless of their insurance status or ability to pay. All of those uncovered ER visits are paid for by the US government, which means all taxpayers.
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Free and low-cost clinics: Many clinics provide services and some medications to those who cannot otherwise afford them. These clinics are paid for by all taxpayers.
[OPTIONAL] The National Association of Free and Charitable Clinics helps people to locate a free and low-cost clinic near them.
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Nonprofits and charities: There are numerous nonprofits devoted to getting care to those who cannot otherwise afford it. Some of these charities will help with out-of-pocket costs for insured people in certain cases as well. They are often in high demand and therefore also have economic criteria for qualifying.
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Crowdfunding: It’s a sad truth that many folks who can’t afford their treatment turn to sites like GoFundMe to pay their bills. Unfortunately, research shows that these crowdfunding campaigns are usually not successful.