Sunday, October 6, 2013

Crohn's, Colitis, and PPACA

Affordable Healthcare Act and IBD

The Patient Protection and Affordable Care Act (pejoratively or positively referred to as Obamacare in certain circles) largely went into effect in the United States on October 1 2013.   No law in recent history has generated as much controversy, ranging from a Supreme Court decision as to its constitutionality to a deadlocked Congress shutting down the federal government, in large part due to arguments over the law.  The reporting of the law is all over the map, and the Onion’s satire (,34022/) isn’t far off in terms of general understanding of the law.(1)  This blog post stays away from the political process and makes no determinations about the overall value of the law, but focuses instead on the impact to those with IBD.  The general impact of the law on cost or breadth of coverage is beyond the scope of this blog.
The full act is extremely dense and a very long read, requiring extensive legalese to interpret it.  A few of the areas, however, are easier to understand and have direct applicability to those who suffer from Crohn’s Disease and Ulcerative Colitis.
The first area with direct applicability is titled “Improving Access to Innovative Medical Therapies”, or the less glamorous “Section VII”.  The primary focus of this section is on creating a mechanism for generic versions of biological therapies to be made available.  The first therapy that is likely to be impacted by those being treated for IBD is infliximab (Remicade), which does not go off-patent until 2018.  Because biologicals are much harder to duplicate than traditional drugs, extensive clinical trials are required for generic manufacturers.  That said, expect the cost of Remicade or its biosimilar brethren to drop precipitously in 2018, followed by Humira and Cimzia a few years later.(2) 
Prescription drug coverage in general is now mandatory under the new act.  Insurers will no longer be permitted to offer an “optional” drug plan, and any costs for drugs count toward your out-of-pocket maximum spend.  Those of us paying thousands of dollars a month on treatments will now have that amount capped, and providers are required to provide at least one drug from every category and class in the US pharmacopeia.(3)
The second area of interest is based on pre-existing conditions.  Traditional health insurance providers were able to discriminate against those with IBD when enrolling in private insurance coverage, either by denying coverage or by charging higher rates.  In 2010, the pre-existing condition contingency was removed for any new insurance coverage issued or applied for if the applicant was under 19 years of age.  In January 2014, insurers will not be able to deny coverage to nor charge higher rates for sufferers of IBD.(4)
Of further interest is the coverage of children and young adults under 26.  Any child under 26 is eligible to be kept under their parent’s plan, even if they are financially independent.  Young adults with IBD who may have intermittent work histories due to illness-related breaks in employment will now have better gap coverage by remaining on their parent’s plans.(5)
How well the affordable care act helps those living below the poverty level will vary by state, and whether the federal government should be involved in healthcare is a debate for another blog.  There are at least a few direct benefits, as detailed above, to those with IBD that will take place over the next several years. 

Bottom Line

·         There are specific benefits in the Affordable Care Act for those with IBD.  These include:
o   Required drug benefits, with an out-of-pocket maximum, even on biological.
o   A new pathway for generic versions of the anti-TNF-alpha drugs in the future.
o   Guaranteed coverage without higher premiums with Crohn’s or Colitis as a pre-existing condition.

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