are not prepared with that kind of money, and you
aren't going to get your medication.
>> There has been some movement in the state's
legislature to address things like copay
accumulators, open formularies and pharmacy
access. We're joined by someone on the front lines
of this work. Rob Gunderman, president and CEO of the
Coalition of Wisconsin Aging and Health Groups.
And thanks for being here. >> Thanks for having me.
>> So tell me a little bit about how you got started
in all of this. >> Sure. Well, I started
getting calls from patients who were trying to get
their medications. They'd go to the pharmacy counter,
and they were being told that it would be thousands
of dollars to get the medication that they're
used to paying 30, 40, $50, whatever their copay was.
And they were learning that a copay accumulator had
been applied to their policy. The one that really
struck me was a woman with a heart condition who
needed this heart medication to live, and she
went up like she always does to buy her medication.
They said it was gonna be $3,800. They didn't have
$3,800. And her husband had to go to the bank and take
out a loan so she could get the medication she needs to
live. And I realized, we have a problem here. And
that woman who I've come to know, she her family is
going into debt more and more every year having to
deal with this. So that's how I got involved in this.
>> And as you've been working on these issues, is
this just all too common? >> You know, when I started
out in this, it wasn't that common. It was I was seeing
in a plan here and people were starting to come to me.
Now it's become very common. It's spreading like
wildfire. There are very few plans left. I don't
even know of a plan left in Wisconsin that doesn't have
a copay accumulator other than the group, the state
insurance plan. >> And there's accumulators,
maximizers and those sound like good things.
>> They do. They use catchy terminology, and they've
probably run this through marketing groups to see
what what people like and what people don't like. But
you're exactly right. There are copay accumulators,
they're copay maximizers. They're all doing
essentially the same thing, but just from a little bit
different angle. You know, when you look at this copay,
accumulator piece, it just to me, this is just so
unfair and I don't it's been difficult for me to
understand how this has been allowed. If you and I
went out to dinner and I paid for your your dinner
and the restaurant said, we've adopted a copay
policy where you have to pay for your your meal and
you say, well, Rob already paid for my meal. Yes. And
we appreciate that. And we're going to keep his
money. But you also have to pay for your meal. You say,
this isn't fair. You're getting paid twice for the
meal. This is what the insurance companies are
fine. you've seen on patients?
What does this do to someone who's making this
impossible decision? >> Well, a couple of things.
One, the financial stress that it's putting families
under that just can't afford this. But the other
piece is I've had people tell me they're not going
to take their medication anymore. I had a friend of
mine who has Ms. And he says if they put one of
these copay accumulators on my policy, I'm going to
stop taking my medication. So you then end up with
more problems with their health. And I don't think
that's a cost saving measure by, you know,
taking this money, they may get some money out of it.
But I think in the long run, the increased health
expenses that you're going to have for people if they
stop taking their medications are going to
offset that. we've seen in these stories,
people don't know until they're so far along that
they owe all this extra money. There's no ability
to have a payment plan for your medications. So you
either get it or you don't. How difficult is it for
people to even know that something like this is on
their plan? How much of it is just poor communication?
>> That's a lot of it. It's very difficult. I've looked
at some of these plans, 50, 60 pages, and who's going
to read 50 or 60 pages of fine print? Some of this is
a very small it's hard to read, especially if your
eyes aren't so good as mine aren't anymore. It's hard
to spot this little clause in there that says, and
even if you read it, if you don't know already what a
copay accumulator is, you're not going to
understand what they're saying in there.
>> Now, Senate President Mary Felzkowski has been
working on legislation like this for many years, many
sessions. What are the concerns that state
lawmakers have had making it so difficult to move
this forward? >> So I think the the one
thing that's really held us up with state law, well, a
couple of arguments that the insurers have made. One
is that this will drive patients to more expensive
brand name medications. We know 98% of the medications
in this group, these expensive medications there
isn't a generic for. But Senator Felzkowski put in
language in the bill saying that this only applies to
medications for which there is not a generic equivalent.
So that's off the table. There's still making that
argument, though. The other argument that we're hearing
is that it will drive up insurance premiums. But
there's studies that have been done looking at states
that have already passed this type of legislation
where the premiums haven't increased. And conversely,
studies have looked at states that haven't passed
this legislation and premiums aren't lower there,
like in Wisconsin, our premiums aren't lower where
we don't have that. >> Where does it currently
stand? And what, if anything, has changed
throughout this session as it's gone through committee?
>> Sure. Well, we had a committee hearing, which
was the first. This is the second session that we've
tried to run this bill, and we weren't able to get a
vote out of committee last session. This session,
we've got a 5 to 0 vote. So the entire committee voted
in favor of passing this out in the Senate. And we
expect that to come up to the onto the floor at some
point in January. We just don't know when. And so,
you know, there's a definite shift here where
the momentum has shifted. I think there are 40
co-sponsors on the bill. But I think I think the
votes are there to pass the bill. If we can get the
votes. next story, that he didn't
know that the formulary had changed. And that's
something that's been a point of contention in the
legislation. Has that changed as it's gone
through committee? >> Yeah. So the insurers
wanted to be able to change the formulary throughout
the year. And right now they could only change it
during the window and people can change plans.
And I said we didn't have a problem with that. As long
as they weren't able to force the patient to change
their medication mid-year. So I think it's actually a
benefit to patients, because if you're going to
to make a formulary change, tell them in June or July,
give them as much time as possible to figure out what
they're going to do and find a new plan that will
cover whatever the medication is that they're
taking that is going to be leaving your formulary. So
I think I don't see a downside to that.
>> Overall, premiums are going up. If people feel
like they're not properly covered under a plan that
they're paying a lot of money for every month, do
you think patients will just end up foregoing a
health plan altogether? >> That's our that's our
concern, our worry. I think there are people who
they're going to look at this and say, I'm paying so
much out of pocket anyway. I'm not ever using the
insurance, so what's the point of having it? And
then when they have something serious happen,
then it's more problems. And it's not like someone
isn't paying for that. >> Now we just saw Congress
go through the longest government shutdown in
history over these enhanced tax credits, and we're
still seeing premiums go up all around. How much of
this is kind of reaching a turning point as healthcare
premiums, costs are all going up and there doesn't
seem to be an end in sight. >> We're getting to the
point where something has to happen and we can't. My
insurance went up almost 25% this year. We can't
have 25% annual increases in our health costs, just
as Americans. We can't afford it. So we have to
figure something out. And I don't know what that answer
is. I mean, people, smarter people than me, have been
trying to figure this out for a very long time. But
we're getting to the point where we have to. This
isn't an option anymore. We can't afford to keep going
the way that we're going. And for a lot of families
without the the Affordable Care Act plans being
available to them, I think available to them, I think