A bipartisan group of House and Senate legislators introduced bills last week that would require health plans to cover the growing number of oral chemotherapy pills as favorably as they do intravenous chemotherapy. But an insurance trade group says that as long as drugmakers continue to increase the prices of the oral drugs, parity legislation amounts to a “shell game” that will push up everyone’s premiums.

In recent years, states have passed oral chemotherapy parity laws at a steady clip. They’re on the books in 39 states and the District of Columbia, according to the American Cancer Society’s Cancer Action Network.

A federal law would ensure equal access across all states, says Anna Howard of the ACS Cancer Action Network.

Proponents also say the bill is needed to because private self-funded health plans that pay their employee claims directly generally don’t have to comply with state parity laws.

About a quarter of chemotherapy drugs in the pipeline are oral cancer medications, Howard says.

Similar bills that were introduced in the previous congressional session didn’t advance. It’s unclear that the current bills have any better chance.

Patients who receive intravenous chemotherapy typically pay a flat copayment (perhaps $50) for an outpatient visit. Oral chemotherapy pills are covered under a plan’s pharmacy benefit, however, where they’re often placed in higher cost tiers that may require coinsurance of 20 percent or more that for some drugs can run thousands of dollars.

Under the health law, consumers are limited in how much they can be required to pay out of pocket annually for care. (The only exception is for enrollees in plans that are grandfathered under the law.)  In 2015, those limits are $6,600 for individuals and $13,200 for family coverage.

Still, “many individuals don’t have an extra $6,600 in their bank account in order to get up to their out-of-pocket maximum,” Howard says.

The proposed bill would require plans to cover chemo pills on terms “no less favorable” than their coverage for IV chemotherapy drugs.

But with the price tag for some oral cancer drugs well into six figures for a course of treatment, consumer premiums are bound to rise if insurers have to absorb the lion’s share of a drug’s cost, says Clare Krusing, press secretary at America’s Health Insurance Plans, a trade group.

“This legislation would place an arbitrary limit on cost-sharing between medical and pharmacy benefits, forcing premiums to increase for all consumers as a result,” Krusing says.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Marlene Allen thought she had decent medical coverage after she fell in December and broke her wrist. She had come in from walking the dogs. It was wet. The fracture needed surgery and screws and a plate.

Weeks later, she learned her employer health plan would cover nothing. Not the initial doctor visit, not the outpatient surgery, not the anesthesiology. She had $19,000 in bills.

“Make sure you find out what kind of plan it is” when employers offer coverage, advises Allen, who lives in northern Minnesota. “I thought health insurance was health insurance.”

A complex health law and bad information helped cause the trouble.

When her employer offered the health plan late last summer she thought she had to sign up. That was wrong.

Once she was on the employer plan, she thought she had to drop better, comprehensive coverage she had bought through MNsure, the state’s online insurance marketplace. That was wrong.

After she learned that her work plan covered hardly anything and tried to get back on a marketplace policy, MNsure told her she’s not eligible for subsidies to buy it. Wrong again.
“Horrible situation,” said Sabrina Corlette, project director at Georgetown University’s Center on Health Insurance Reforms. It “does make you wonder about the training these call-center folks are getting.”

Last September, with an impending January deadline for employers to provide insurance under the health law, Allen’s employer introduced a plan covering only vaccines, blood-pressure tests and other preventive care.

Skimpy though they are, such benefits meet one of the law’s tests — the one that says employers must offer “minimum essential coverage” or pay a fine of about $2,000 per worker. (They do not pass a second requirement — that employer coverage offer “minimum value” including hospitalization. Flunking that test can result in a different fine of up to $3,000 per worker.)

Allen works for Independence Plus, a home-care agency. She takes care of her disabled son, who has multiple sclerosis, and gets paid through a state program as the company’s employee.

Last fall, she joined the agency’s minimum essential coverage plan and dropped her comprehensive MNsure plan. She knew the new coverage wasn’t great, but she thought it would at least cover surgery. She believed she was obligated to take the coverage and didn’t notice that the insurance card says, “Preventive Services Only.”

She was shocked when she learned it covered none of the charges for her broken wrist. She had always been careful to have medical insurance. Now she faced hospital bills for more than half her annual income.

“I don’t even want to call it a health plan,” she said. “It should be illegal.”

Minimum essential coverage, or MEC, policies, also known as “skinny plans,” spread last year as lower-wage employers such as temp agencies and hotels adopted them as a shield against the $2,000 fine. Unlike Independence Plus, many employers supplement skinny plans with other health insurance, although even some of those lacked hospitalization benefits until federal regulators moved to ban them.

“There aren’t too many companies that are doing just MEC plans,” said George Reardon, a Houston benefits lawyer who works with staffing companies.

Independence Plus can’t afford more comprehensive benefits or even get insurers to offer them because of high worker turnover, said CEO Ruby Baranski. She blames President Barack Obama and the Affordable Care Act for forcing her to offer a minimal plan to avoid the $2,000 per-employee fine.

“I kind of got slapped with this,” she said.

Faced with no way to pay her huge bill, Allen applied for assistance from the health system that fixed her arm. Sanford Health would not comment on her case, but on June 3, it sent a letter agreeing to wipe out its entire, $17,200 bill, leaving only a $1,800 charge from the anesthesiologist.

She is grateful. But she’s also worried because the skinny, preventive-only plan is still her only health insurance. In February she told a MNsure rep she wanted to get back on a marketplace plan.

She told MNsure her workplace plan didn’t cover hospitalization. She asked whether she could get subsidies to buy a comprehensive MNsure plan — the only way she could afford it, with her $37,000 income.

No, MNsure said. Because Allen was offered an affordable plan at work, she could not get tax credits to help pay for a marketplace plan, MNsure said.

That’s the wrong answer. All consumers in Allen’s income range get subsidies unless an employer plan is both affordable and meets the minimum value test with hospital, doctor and drug benefits. (Or unless they’re eligible for a government program like Medicare.)

Independence Plus’s plan is affordable, but because of its skinny, preventive-only benefits it falls far short of minimum value under the law.

Once Allen learned she had gotten bad information, MNsure’s regular enrollment period for 2015 was over and it was too late to sign up. She applied for an exception so she wouldn’t have to wait until next year to get covered.

MNsure spokesman Joseph Campbell acknowledged the error but said it was a rare exception. The marketplace’s employee training manual addresses both affordability and minimum value, he said.

But on Wednesday Allen got a letter stating again that she is ineligible for tax credits because she has access to insurance elsewhere.

“Boy, something is so wrong with this,” she said.

The bigger lesson, Allen said, is: Don’t assume insurance offered by your employer is real medical coverage.

“You think when the word insurance is said it should cover you for everything,” Allen said. Now she knows that’s not true.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Pharmacists in California will soon be able to prescribe birth control. That’s under a new state law that grants expanded authority to pharmacists. While some doctors’ groups are skeptical, lawmakers say pharmacists can fill a need for primary care providers, especially in rural areas. Reporter April Dembosky of KQED in San Francisco filed this story on the new law which will start going into effect as soon as the fall. This is an edited transcript of the radio story that aired on NPR’s All Things Considered on June 16, 2015.

APRIL DEMBOSKY: Think of how often you stop by your local drugstore. You run in and grab some BAND-AIDs, maybe get a flu shot on your way to work. Soon, it will be that easy for women in California to get birth control.

Lisa Kroon is a professor at UC San Francisco’s School of Pharmacy and overseas students who work at this Walgreens store on campus. It will be one of the first to take advantage of a new law in California allowing pharmacists to prescribe hormonal contraception, including the pill, the ring and the patch.

LISA KROON: For a woman who might need a refill, can’t get in to see their doctor, the pharmacist will be able to furnish that for them now.

DEMBOSKY: The law goes way beyond birth control pills. It also authorizes pharmacists to provide medications for smoking cessation and travel abroad. They can even order lab tests and adjust drug regimens for patients with diabetes or hypertension. Kroon says the idea is to make it easier on patients.

KROON: Maybe a working parent can now come after work because the pharmacy is open later.

DEMBOSKY: The law was passed amidst growing concern about lack of access to primary care providers. That’s with baby boomers hitting 65 and getting Medicare. At the same time, millions of people are also now getting health coverage under the Affordable Care Act. Kroon says California is one of the first states to recognize that pharmacists can help address the need.

KROON: The pharmacist is really an untapped resource. We are graduating students that are ready for this, but the laws just haven’t kept up with what the pharmacist training already is.

DEMBOSKY: But pharmacists’ growing power makes some doctors uncomfortable. The California Medical Association originally opposed the bill, citing patient safety concerns. It withdrew its opposition after lawmakers added a special licensing procedure and continuing education requirement for pharmacists. Still, some doctors are concerned that if women don’t come to the clinic for their birth control, they won’t get screened for cervical cancer or tested for sexually transmitted diseases. Amy Moy is with the California Family Health Council.

AMY MOY: Family planning for women is often an access point to assessing other health issues.

DEMBOSKY: Her group helped support the law with caveats.

MOY: Women accessing birth control through the pharmacist would be faster — and more convenient in some cases, but they will also not have the more comprehensive care available in another health care setting.

DEMBOSKY: Still, she says the benefits of reducing unplanned pregnancies outweigh the potential downfalls. And pharmacy professor Lisa Kroon says the plan is for pharmacists to communicate regularly with patients’ doctors.

KROON: We are not a lone ranger out there doing something.

DEMBOSKY: Other states are watching California to see how the law is implemented. Oregon is considering a similar measure. For NPR News, I’m April Dembosky in San Francisco.

This story is part of a reporting partnership that includes NPR, KQED and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.