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New analysis shows Obamacare exchange plans restricting access to life-saving prescriptions

by | Mar 26, 2014


By Jennifer Popik, JD, Robert Powell Center for Medical Ethics

Jennifer Popik, JD

Jennifer Popik, JD

A new analysis out from consulting firm Avalere Health shows the denial of life-saving medication is rampant in the new Obamacare exchange plans.

Elise Viebeck, in her March 24, 2014, piece from The Hill “Prescription drugs: Harder to get in O-Care?” writes,

ObamaCare participants are twice as likely to face administrative barriers to using certain prescription drugs as people who receive health coverage through an employer, according to a new analysis. The research from consulting firm Avalere Health points to a little-known facet of policies on the ObamaCare exchanges known as “utilization management controls.” The controls allow insurance companies to limit access to certain medications to try and control costs and prevent abuse. People who enroll in ObamaCare plans are likely to encounter the hurdles if they’re prescribed brand-name cancer or mental health drugs, Avalere found.

At least 51 percent of brand-name mental health meds come with special controls on the exchanges, compared with only 11 percent on the employer-based market, the analysis found….The controls may include policies like “step therapy,” when patients must try cheaper medications before receiving coverage for an alternative that costs more, or “prior authorization,” which means an insurer grants coverage of prescriptions on a case-by-case basis.

As Obamacare continues to roll out, it has faced trouble on many fronts. As signups lag behind target, the Obama Administration announced a new delay, meant to entice people into the state health care exchanges. On March 26, 2014, the Administration gave an extra window for enrollees who had begun (but haven’t completed) the Affordable Care Act signup process by the March 31 deadline.

All throughout the debate leading up to the controversial 2010 law, and up until late last year, the Obama Administration kept asserting that “if you like your plan, you can keep it.” But by last December, the fact checker PolitiFact was awarding this assurance its “Lie of the Year” for 2013.

When hundreds of thousands having lost plans they liked, the administration moved on to its next claim–that “the new exchange plans would be better than your old plan.” This new promise is already proving to be at odds with the facts.

As millions of Americans are attempting to start using their new Obamacare exchange health insurance plans, stories about denial of payment keep piling up. You can read more on this here.  The limits on prescription drug coverage are just the latest evidence.

While many are quick to blame insurance companies, the real culprit is the Obamacare provision under which exchange bureaucrats must exclude insurers who offer policies deemed to allow “excessive or unjustified” health care spending by their policyholders. Prescription drugs are often a costly part of these plans.

Under the Federal health law, state insurance commissioners are to recommend to their state exchanges the exclusion of “particular health insurance issuers … based on a pattern or practice of excessive or unjustified premium increases.” The exchanges not only exclude policies in an exchange when government authorities do not agree with their premiums, but the exchanges must even exclude insurers whose plans outside the exchange offer consumers the ability to reduce the danger of treatment denial by paying what those government authorities consider an “excessive or unjustified” amount.

This means that insurers who hope to be able to gain customers within the exchanges have a strong disincentive to offer any adequately funded plans that do not drastically limit access to care. So even if you contact insurers directly, outside the exchange, you are likely to find it hard or impossible to find an adequate individual plan. (See documentation at

When the government limits what can be charged for health insurance, it restricts what people are allowed to pay for medical treatment. While everyone would prefer to pay less–or nothing–for health care (or anything else), government price controls prevent access to lifesaving medical treatment that costs more to supply than the prices set by the government.

While Obamacare continues to roll out in 2014, it is important to continue to educate friends and neighbors about the dangers the law poses in restricting what Americans can spend to save their own lives and the lives of their families. You can follow up-to-date reports here:

Categories: ObamaCare Rationing