Why Women Struggle to Pay for Prescriptions
The problem is even worse for those who have chronic conditions, a survey says
A former professional tennis player and NCAA All-Southeastern Conference student athlete, Elizabeth Moorman was trying to conceive her second child when she began suffering from severe headaches, chronic pain, congestion and sinus infections so severe that she underwent four surgeries.
“I told my doctor, ‘I’m the sickest well person you’ve ever seen,’” recalled Moorman, a senior physical therapist for the Children’s Rehabilitation Service in the Alabama Department of Rehabilitation Services. “I was a professional tennis player, I’ve run marathons, but I was constantly sick.”
Immunological tests discovered Moorman, now 55, suffered from common variable immune deficiency (CVID), a chronic disorder that impairs the immune system, sometimes leading it to attack the body’s healthy tissues and organs. Moorman’s treatment was monthly, lifelong intravenous infusions of immunoglobulin replacement therapy designed to bolster her immune system.
Her struggles with CVID, and a subsequent diagnosis of an unrelated neurodegenerative condition, have given Moorman a front-row seat to the complexities and unpredictability of the nation’s health care system.
Her CVID treatment costs an astonishing $20,000 a month. Insurance initially picked up most of the tab, but a decade after her initial diagnosis, Moorman found her co-pays began to mount. A financial hardship petition to the pharmaceutical company offset those new expenses for a few years, but that assistance was abruptly terminated. “They cut out their financial hardship program entirely,” said the single mother of two teenage boys.
Survey Highlights Financial Stresses
Moorman’s experience is mirrored in the findings of WomenTALK 2018, a national survey conducted by HealthyWomen, an independent, nonprofit health information organization. Although 86 percent of the female respondents have health insurance, the survey found:
- 37 percent struggle to pay for their prescription medications, a number that jumps to 48 percent for patients with chronic conditions like Moorman's.
- 52 percent rely on financial assistance from family or friends to pay for their medications, while 41 percent receive help from pharmaceutical companies via discount cards or coupons. More than one-quarter get assistance from a nonprofit.
- 81 percent of women with a chronic condition rate prescription drug coverage as their most important health insurance plan benefit.
Moorman, who holds two graduate degrees from top U.S. universities and is the daughter of a retired physician, approached the owner of a Birmingham-area infusion company who agreed to honor her hardship petition and now provides treatment for what her insurance company pays.
“It just makes me really sad for other people,” said Moorman, whose role with the state health department means she often treats children of low-income families. “I sort of know how the system works. A lot of my clients don’t really know how to navigate the system. I was just savvy enough to look around and make something happen that I could afford.”
Even so, “you have to submit all kinds of deeply personal information. It can be humiliating,” she said. "You do what you have to do.”
Americans With Chronic Conditions Hit Harder
Moorman’s assessment is spot on, said Stacey Worthy, an attorney and partner at DCBA Law & Policy, a Washington, D.C. firm that assisted HealthyWomen in designing the survey and evaluating the results. “Even if they have health insurance, many individuals with chronic conditions still can’t afford their treatment,” Worthy said.
Advances in medical science and populations that live longer are leading to a significant increase in the number of people living with one or more chronic condition, according to a 2018 study based on statistics from the Centers for Disease Control. Some 80 percent of older Americans have at least one chronic condition and 77 percent have at least two, according to information released in 2018 by the National Council on Aging (NCOA). The most common chronic diseases in Americans older than 65 in 2017, according to NCOA, were:
- High blood pressure
- High cholesterol
- Coronary heart disease
- Chronic kidney disease
- Heart failure
- Alzheimer’s disease and dementia
- Chronic obstructive pulmonary disease
A 2017 study by the nonprofit Rand Corporation found that patients with multiple chronic conditions face much higher health care expenses and often have worse health outcomes. Women are even more vulnerable because they have a much higher prevalence of multiple chronic conditions, according to the Rand study. Women in their late 50s and early 60s who have retired or are no longer working but aren’t yet eligible for Medicare are often at greatest risk, Worthy noted.
Insurance Companies Use 'Switching' and 'Stepping'
The HealthyWomen survey identified two major “cost-containment” strategies health insurers use to reduce their prescription expenses: nonmedical switching and step therapy.
Nonmedical switching forces patients to switch to a less-expensive treatment for no medical reason, often in the middle of a coverage year. Examples include insurers suddenly dropping a medication from coverage, abruptly requiring prior authorization for a drug the patient has been effectively taking or significantly increasing co-pays to the point that a patient can no longer afford the medication.
The HealthyWomen survey found that 39 percent of women with chronic health conditions said their medication coverage deteriorated last year, requiring 45 percent to change from their originally prescribed medications. Of those patients, more than a third said the substituted medication didn’t work as well or had harmful side effects.
Insurers use step therapy, or “stepping,” to force patients to try one or more treatments different from what was originally prescribed and have those treatments deemed ineffective before the originally prescribed medication will be covered. The survey found that 25 percent of women with a chronic health condition have been subjected to stepping.
“In some plans, a patient will go through prior authorizations and step therapy, and the next plan year rolls around, and the insurer requires the patients to fail again on medications they’ve already failed on,” Worthy said. “We’ve even seen step therapy for cancer treatment.”
Reform and Education Initiatives
Organizations such as HealthyWomen are advocating for policy and education initiatives to counteract the consequences of making medications for chronic conditions cost-prohibitive, Worthy said. These include:
- Ensuring patients have access to assistance, either through nonprofits or pharmaceutical co-pay assistance programs.
- Reforming insurers’ so-called “co-pay accumulator programs” allowing co-pays patients make to count toward their health insurance deductibles. (Many plans do not apply patient co-pays toward deductible requirements.)
- Educating employers and women about plans that rely on these tactics to reduce or limit coverage, and highlighting plans that more completely cover patients’ health care needs.