End-stage renal disease is not only physically overwhelming but can also be financially devastating. Although most ESRD patients become eligible for Medicare three months after diagnosis, Medicare requires patients to pay a 20 percent coinsurance with no out-of-pocket limit —patients average $7,000 in out-of-pocket costs annually. And in 23 states, Medigap is not required to be made available to ESRD patients under age 65. Congress has allowed ESRD patients to stay on private health plans, which provides an option for patients who can afford to stay on their private insurance. Many low-income individuals need assistance to exercise the option of staying on their private insurance.
As Congress attempts to repeal/repair/replace the Affordable Care Act, the American Kidney Fund is fighting to protect the access of patients with ESRD to affordable and high quality health care. AKF has a list of principles to guide our support:
- Pre-existing Conditions – Prior to the ACA, there were individuals who could not find insurance due to a pre-existing condition. Pre-existing condition clauses made it nearly impossible for ESRD patients on dialysis to find an insurance plan because, from the insurers’ point of view, they are too expensive to cover. ESRD patients are unique in that many patients find out they are in kidney failure and need to start dialysis immediately; they don’t have time to prepare for a transition to dialysis and finding alternative insurance. If, for instance, an ESRD patient were on an employer’s insurance and lost that coverage due to leaving work, they would not be able to find another plan. AKF opposes continuous coverage provisions because ESRD patients would find themselves in similar situations as they did prior to the ACA. Most ESRD patients are too ill to work, and they lose their insurance due to leaving their job. If they get a kidney transplant or become healthy enough to work, they will not be able to access the private insurance market if the only protection is found in “continuous coverage.”
- Adequate Premium Tax Credit – The replacement plan must have an adequate premium tax credit to ensure that consumers can afford health insurance plans. ESRD patients must have dialysis or a transplant to survive. Most patients go to dialysis three times a week for four to six hour sessions. The time needed for proper care takes away from the time that someone can work, and dialysis patients are usually too sick to work. The lack of an income means that in order to fully access the private insurance market, they need premium tax credits that cover enough of the premium so ESRD patients can exercise their choice to buy the private insurance plan.
- Market Stability – The timeline for repeal of the ACA should correspond to the replacement of a new plan. The continuity of access to health insurance is especially important for individuals with ESRD who need continual access to dialysis. Ensuring that they have health insurance options is a matter of life and death to ESRD patients, and Congress should provide consumers with a seamless transition from the ACA to a replacement plan. Any aspects of the repeal plan that may make health insurance out of reach to a consumer, such as prematurely ending advance premium tax credits (APTC) or cost-sharing funds, should be rejected. Insurers will need time to craft the new health plans that adhere to new laws, and ESRD patients will need to be able to access ACA plans until the new plans are an option.
- Working to ensure access to ESRD pharmaceuticals on insurance drug formularies
Creating formularies that treat drugs for chronic diseases differently than other drugs is a way insurance carriers can deter those with chronic diseases from buying their insurance plan. Insurance carriers can put all needed drugs in the top tier, which means that consumers would have to pay the most expensive copay. They can also limit certain drugs to the most expensive plans that are not eligible for tax-credits. AKF continues to monitor these practices.
- Essential Health Benefits – Retention of essential health benefits in any new plan is vital for consumers. Health insurance policies can be complicated, and individuals believe that when they purchase health care insurance, their health care needs will be met. If insurers are allowed to return to creating policies that don’t cover certain ailments, there will inevitably be consumers who are left without coverage. There needs to be a baseline of benefits that will cover the health needs of the person who purchases it. Since people don’t know what their medical conditions may be, they need to be assured that their health plan will cover whatever disease or illness they may get. It is especially true of individuals who find themselves diagnosed with a chronic diseases like ESRD. If insurers are allowed to write policies that do not cover chronic illnesses, consumers will be hurt. Only with mandating that insurers cover these illnesses, will insurers create plans that provide all of the health care services that the consumer may require.
- Election of Tax Credit Instead of Government or Group Plans – ESRD patients are eligible for Medicare 90 days after starting dialysis treatment. However, some ESRD patients would prefer to stay on private insurance. In the new health care law, AKF supports continuing to allow individuals to choose to utilize tax credits to pay for their private insurance rather than going on Medicare.