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Improving Patient Affordability of Medicines


Sponsored by: Rep. Joseph Miró (DE), Sen. Iris Martínez (IL) and Sen. Carmelo Ríos (PR)

WHEREAS, medicines are a great investment in improving patient health and reducing overall cost to the broader health care system; and,

WHEREAS, new medicines provided 73 percent of the total increase in life expectancy between 2000 and 2009, and every additional dollar spent on medicines for adherent patients with congestive heart failure, high blood pressure, diabetes and high cholesterol generates $3 to $10 dollars in savings on emergency room visits and inpatient hospitalizations; and,

WHEREAS, spending on prescription medicines has been and is projected to remain stable, accounting for just 14 percent of overall health care spending in the U.S., and,

WHEREAS, in many jurisdictions, a patient’s health insurance coverage can control his or her access to medicines through utilization management requirements such as prior authorization, step therapy or fail first, quantity limits, formulary exclusions and dose limits; and,

WHEREAS, a patient’s health insurance coverage determines what he or she pays “out-of-pocket” at the pharmacy counter for the medicines they need; and,

WHEREAS, a patient’s out-of-pocket cost for a medicine has a direct impact on adherence, and a patient may choose to not start or to discontinue therapy if the out-of-pocket cost is high, which can have a direct impact on a patient’s health and may result in more downstream costs to the health care system; and,

WHEREAS, patients are 80 percent more likely to abandon therapy for MS if their out-of-pocket costs reached $100-$250 compared to $0-$50, and patients with higher cost-sharing for their tyrosine kinase inhibitor for chronic myeloid leukemia (CML) are 70% more likely to discontinue therapy; and,

WHEREAS, when health plans use co-pays, patients pay a predictable price for medicines, but as more health plans utilize prescription drug deductibles and co-insurance, patients are exposed to higher costs early in the plan year and receive no benefit from their insurance plan to help reduce these costs; and,

WHEREAS, in some geographies, a patient may have no choice but to enroll in a plan with a high deductible and co-insurance for medicines; and,

WHEREAS, while drug manufacturers provide health plans and pharmacy benefit managers (PBMs) with discounts and rebates to lower the price the health plans and PBMs pay for medicines, in some cases patients may still be forced to pay the full price for the drug before meeting their deductible or when paying co-insurance.

NOW THEREFORE BE IT RESOLVED, that prescription medicines are a critical tool in preventing, treating and curing disease; and,

BE IT FURTHER RESOLVED, that patients should have insurance options that allow them to choose between different benefit designs for medicines, including options with fixed copays and no deductibles, and some of the savings negotiated by manufacturers and health plans and PBMs should benefit patients.


  1. Adapted from: Lichtenberg, F.R. (2012). Pharmaceutical Innovation and Longevity Growth in 30 Developing and High-Income Countries, 2000-2009. Working Paper 18235. National Bureau of Economic Research.
  • M.C. Roebuck et al. “Medication Adherence Leads to Lower Health Care Use and Costs Despite Increased Drug Spending.” Health Affairs, January 2011.
  • Altarum Institute. “Center for Sustainable Health Spending Data Brief: A Ten Year Projection of the Prescription Drug Share of National Health Expenditures Including Non-Retail, Addendum Update August 2015”, p. 6. A.vailable at: http://altarum.org/sites/default/files/uploaded-publication-files/Non-Retail%20Rx%20Forecast%20Data%20Brief_with%20Addendum.pdf
  • American Medical Association. Addressing Prior Authorization Issues. Retrieved form: https://www.ama-assn.org/practice-management/addressing-prior-authorization-issues
  • The language in the referenced paragraph should not be taken as an endorsement by NHCSL of these practices. They are listed because they are a fact of life for many patients. A considered judgment of these practices is beyond the scope of this Resolution but may be addressed in future Resolutions of this Caucus.
  • U.S. Department of Health and Human Services. Health Care in America: Trends in Utilization, p. 6. Retrieved from: https://www.cdc.gov/nchs/data/misc/healthcare.pdf
  • PrimeTherapeutics, https://www.primetherapeutics.com/content/dam/corporate/Documents/Newsroom/PrimeInsights/2014/research-posters/0414spring-specialty-rx-abandonment.pdf
  • S. Dusetzina, Journal of Clinical Oncology Dec, .2013.52.9123