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Awaiting Kotek’s signature: a health care bill to help patients’ pockets

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A bill passed by the Legislature during the 2024 session would require insurers to count copays toward a patient’s deductible. (Getty Images) Getty Images

By MADONNA MCGUIRE SMITH || OREGON CAPITAL CHRONICLE

$25,000 per dose. That is how much my son’s bi-weekly medication for his chronic bleeding condition can cost our family. Copay assistance has been a lifeline for us.

But that assistance has not counted toward his deductible. That would change if House Bill 4113, which awaits Gov. Tina Kotek’s signature, becomes law. The bill would codify crucial protections for patients across Oregon by banning policies that exclude copays and copay assistance from counting toward a patient’s deductible.

Prescriptions are a big medical expense. One-third of Americans struggle to afford their medications. For many, copay assistance serves as a lifeline. Unfortunately, without the proper legislation in place, profit-driven pharmacy benefit managers and insurers can exploit these assistance programs by diverting copay assistance away from counting towards a patient’s deductible. The AIDS Institute’s 2024 report found that this is happening in five out of six health plans available in Oregon’s health insurance marketplace in 2024.

This isn’t just about lining corporate pockets; it has serious consequences for those affected. Soaring costs deter patients from seeking necessary treatment. A recent study by IQVIA, a health care analytics company,  showed that “prescriptions without out-of-pocket costs have an abandonment rate as low as 5%” while when “out-of-pocket costs are over $125, abandonment rates sit at 45%”.

The repercussions of abandoning treatment are wide: Patients suffer, and the health care system incurs long-term costs. We can’t ignore this issue; it demands immediate and substantive attention. Oregon’s state Legislature recognized this urgency by passing HB 4114.

While HB 4113 is an important step, it can’t extend protection to every patient in Oregon. Most employer-sponsored insurance plans are federally regulated, meaning federal legislation is required to ensure protection for every patient.

Fortunately, the bipartisan HELP Copays Act (HR 830 and S. 1375) in Congress has the potential to solve that. This act ensures that any amount paid by, or on behalf of, a patient is counted towards the patient’s deductible, co-insurance, co-payment, or limit, nationwide.

For families like mine in Oregon, this legislation has the potential to be life changing. With a husband and four children battling a chronic bleeding condition, expensive medications are often required. Copay assistance helped us cover our yearly out-of-pocket maximum of $5,000.

If the governor signs HB 4113, families across the state will finally have peace of mind that every dollar spent will count towards our maximum. But for families with employer self-funded insurance like mine, the risk of copay assistance diversion will remain just as prevalent.

If this bill becomes law, Oregon will join 19 other states, DC, and Puerto Rico in helping to protect the most vulnerable populations. But If we want to build on our success, we should turn our attention to pairing our state law with the federal bipartisan HELP Copays Act, ensuring that every family in Oregon finally gets the protection that they deserve.

Madonna McGuire Smith  Madonna McGuire Smith is a Corvallis resident and longtime advocate for Oregon’s patients. She currently serves as the executive director of Pacific Northwest Bleeding Disorders.

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