Pharmacy & Therapeutics - September 2008 - (Page 544)

COMMENTARY Universal Health Care in America: Can the Massachusetts Model Work Nationwide? Miriam Reisman The general election is fast approaching, and the universal health care debate is back for another round. But will this year prove any different for an idea that has been batted around in this country for the last 100 years? And if the next president does achieve universal care, what will it mean? How will it affect insurance premiums, prescription drug coverage, and other basics of health care delivery? These are critical questions for stakeholders, including the millions of consumers who have consistently ranked health care as a top election-year priority.1,2 According to a recent public opinion poll, health care reform is the third most important issue—behind the economy and Iraq—that voters want presidential candidates to address during the 2008 campaign.3 But although universal care is certainly a hot-button topic for stump speeches and press releases, it might be better addressed through a look at a real-life model of reform—the Massachusetts Health Care Law. As of January 1, 2009, the requirements for a health plan to satisfy the state’s “minimum creditable coverage” (MCC) standard become more stringent. For instance, by this deadline, an MCC-level plan must have low deductibles—no more than $2,000 a year for an individual or $4,000 for a family—and it must include prescription drug coverage.7 MANDATING PRESCRIPTION DRUG COVERAGE Massachusetts was the first state to establish standards that apply to every resident, and it is the first to require that adults older than 18 years of age have a plan that mandates drug coverage.8 The minimum standards allow plans to charge an additional deductible for drugs of up to $250 for an individual. Many in the state’s health care community, including employer groups and insurance companies, oppose the drug mandate, calling it a burden for those who already cannot afford to add prescription benefits to their coverage.9 (Currently, approximately 160,000 people in THE MASSACHUSETTS PLAN Massachusetts have either a no-drug plan or a plan with less than the required drug coverage In 2006, Massachusetts Governor Mitt Romney under the state’s new law.7) In addition, there is the signed into law a bill that requires all residents of Miriam Reisman the state over 18 years of age (with some excepconcern that prescription benefits, although tions) to obtain and maintain a minimum level of health insurmandatory, will still be a difficult sell to those young, healthy ance. The individual mandate, which went into effect on July patients who might not think that they need to add drug cov1, 2007, includes an escalating series of fines or tax penalties erage to their plan.8 for those who do not comply. With the January deadline looming, the state has been lookWith this landmark health care initiative, enacted as Chaping for ways to keep premium prices under control without ter 58 of the Acts of 2006 of the Massachusetts Legislature, the compromising access to most prescription drugs. The Connecstate became the first in the U.S. to achieve “near-universal” tor staff was charged with developing a feasible strategy to health insurance, guaranteeing coverage for virtually all of its accomplish this and has been working with the program’s parresidents. In addition to imposing mandates on all residents, ticipating insurance carriers to design more affordable plans.10 Chapter 58 requires that employers with more than 10 employTheir recommendations include the use of increased member ees cover their workers or pay a “fair share assessment” fee cost sharing and a more limited, therapeutically based formuof up to $295 per employee per year.4 The law includes insurlary, as well as other cost-containment approaches such as step therapy, prior authorization, quantity limits, and mandatory ance subsidies for low-income residents, with the poorest paymail order for maintenance medications.10 ing no premiums. Those who do not qualify for subsidies and cannot get coverage through their jobs can buy low-cost plans Health New England (HNE), a local carrier in Western Masoffered by selected private insurers through the Commonsachusetts that has been participating in the Connector prowealth Health Insurance Connector Authority (“the Connecgram since its inception, currently offers a Silver plan option tor”), an independent state agency that links individuals and with a generic-based formulary. The “Performance Formulary” businesses with affordable health insurance products.5 Plans has a two-tier structure. Tier 1 includes all generic drugs, and Tier 2 includes a limited number of brand-name drugs carefully offered through the Connector range from $122 to more than selected based on clinical efficacy and cost efficiency. At least $800 a month, depending on coverage, location, and age.6 one medication is available to treat each disease state. AccordThese policies may also be purchased directly from the indiing to HNE Medical Director Thomas Ebert, MD, the Performvidual carriers. ance Formulary was developed in response to the state’s new prescription drug mandate. The author is a medical writer living near Philadelphia, Pennsyl“It was a burden from a cost perspective,” he said of the manvania. date. “But it was an opportunity that allowed us to experiment with a robust pharmacy benefit with restrictions.” Accepted for publication August 15, 2008. 544 P&T® • September 2008 • Vol. 33 No. 9

Table of Contents Feed for the Digital Edition of Pharmacy & Therapeutics - September 2008

Pharmacy & Therapeutics - September 2008 Contents Editorial Medication Errors Prescription: Washington New Drugs/Drug News/New Medical Devices Drug Forecast Effect of Prescription Copays on Adherence and Treatment Failure with Oral Antidiabetic Medications Vaccine Declinations Present New Challenges for Public Health Universal Health Care in America Digestive Disease Week and American Diabetes Association Pharmaceutical Approval Update

Pharmacy & Therapeutics - September 2008

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