Your State of Public Health: The 2020 Insulin Cap

Alan Fijalkowski 500x500Article by Alan Fijalkowski

Colorado has been making headlines across the nation for many different reasons. One, in particular, is the passing of a state law that caps the co-pays for insulin at $100 per month. News outlets across the nation have highlighted this new law, citing several other states that are looking to Governor Polis for help implementing such in their state. The law creates the ability to save several hundreds of dollars per month for those that rely on the life-saving drug, and it will undoubtedly reduce the burden of such on those affected. However, the fact is that nothing is ever as simple as it seems. Furthermore, if it seems too good to be true, it most likely is. Unfortunately, this topic is not exempt.

Discussions among the public health world brings plenty of concern, much due to the lack of safeguards and verbiage of the act. As it can be easily assumed, if it is not explicitly written, it leaves everything open to interpretation. This is a continual concern for myself and my peers in the public health world, which is that while intentions may be right, the availability to exploit or circumvent the situation is present unless it is safeguarded in the law. Do not get me wrongwe are all supportive of the effort, we want to make sure it works, and people are not exploited because of it. To do this, we tend to look at these aspects from the insurer’s point of view as well as the insured. We do this to find potential gaps, lapses, and voids in the legislature, in the hopes of identifying them to protect the public and lobby for revision when needed.

The key is to take every piece of information with a certain degree of skepticism. Can it be as simple as it sounds? Not likely. My main concern is that not everyone in Colorado will see this benefit. Because this is a state law, it can only apply to the 150+ health insurance agencies and policies that are authorized in the state of Colorado. This means that Medicare recipients will not be eligible, as that is a Federal program (unless they have a supplement program that is authorized through the state.) Other potential exemptions are employer-funded health programs that are exclusive to the employer and not available on the marketplace, as well as religious cost-sharing programs.

My secondary concern is the verbiage with the limit to 30-day supply caps. If a consumer needs to replace his or her supply due to a lost prescription, damaged vial, or even fluctuations in dosages due to physiological changes, there is the chance they may have to pay the full price. It also brings concern over fulfillment, in the event a consumer wishes to refill a day or two early or needs to obtain a refill early in preparation for travel. If it is within a 30-day window, it yields the potential to be denied, putting the full price burden on the consumer. The Affordable Care Act states that insurance agencies cannot increase the premiums on policies more than 15% without establishing a public explanation for the increase. While they cannot specifically increase your policy, they can potentially increase everyone’s premiums to offset the additional costs incurred by the insulin cap. While this is a theoretical concern, it is essential to keep these possibilities in mind, so you are not surprised if they do happen. Some providers have already established their 2020 Prospectus, claiming to see a negligible, or “de minimus,” cost increase, and will not significantly impact rates.

The act itself almost immediately exempted high-deductible health plans from this process, as deductibles would still have to be met before the insurance benefits would even begin to take effect. The IRS helped to solve the problem this past summer by categorizing insulin as a preventive medicine to reduce illness, making it effective regardless of deductible. This is a prime example of how minimal verbiage within a law still leaves much to be assumed to interpret. This does not mean the law is a poor choice, but quite the opposite. The law is a fantastic step in a positive direction for Coloradans. We must always remember that when new laws, legislation, and policies are implemented, they will still need to be tested and refined. It is never going to be perfect straight out of the gate. After all, our own Constitution is designed to ensure we can make changes to such, and we have to be patient while these issues are finely tuned for accuracy and protection.

One thing I have learned in the world of public health is that our vast access to information is more often detrimental than it is beneficial. Mass media and news outlets produce eye-catching and emotional response headlines on social media. Many times, these headlines are shared and commented on without the actual article ever being read. Moreover, the true nature of vital information is frequently shrouded and lost in the world of social media. Take everything with a grain of skepticism. Read thoroughly and think critically.


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