Rising health care costs continue to put treatment out of reach for vulnerable communities in San Diego and across California, including many people living with mental health issues. Healthcare providers are reporting an increase in anxiety, depression and addiction due to the COVID-19 pandemic, economic fears, job loss, rising cost of living and many other factors.
Without meaningful efforts to address the cost of health care — and especially what San Diego patients pay over the pharmacy counter — we risk exacerbating a health crisis as patients delay or forgo treatment altogether. .
A growing body of evidence suggests that the impact of expensive healthcare costs is already negatively impacting the mental health of California patients and their families. A California Health Care Foundation 2021 Survey found that more than half of Californians skipped or postponed mental and physical health care due to cost.
And, according to a survey by Kaiser Family Foundation57% of Californians said they couldn’t access the behavioral health care they needed.
California policymakers have tried over the years to improve what patients pay out of pocket for their drugs, including reforming the prescription drug reimbursement system. This year, Senate Bill 1361 would have increased transparency in the opaque business practices of Pharmacy Benefit Managers (PBMs) and required that 90% of manufacturer discounts be passed on to consumers at the pharmacy counter.
Health insurance companies and PBMs negotiate deep discounts and rebates when purchasing drugs from drug manufacturers. The price they pay after the discount is lower than the “list price” of the medicine. On average, pharmaceutical manufacturers reimburse 40% of the list price of a drug.
In 2020, the Department of Managed Healthcare reported that health plans received more than $1.4 billion in rebates, up 57% from 2017. Due to a lack of transparency and liability, there is no requirement that health insurance plans guarantee that patients benefit from these discounts.
Adoption of SB 1361 would have helped reduce patients’ out-of-pocket expenses for their prescription drugs and increased adherence to their treatment regimens. Unfortunately, California lawmakers have once again been unable to reform the byzantine drug pricing and reimbursement system that health insurers and pharmacy intermediaries use to generate profits on the backs of patients.
According to San Diego County Health and Social Services Agency, approximately 1 in 4 adults in San Diego County experience a mental health issue. Nationally, 1 in 5 adults suffer from mental illness and 1 in 20 suffer from serious mental illness, according to the National Alliance on Mental Illness.
Patients with mental illness face a number of barriers to successfully treating their illness, including the lingering stigma surrounding mental illness and barriers to proper diagnosis. Managing mental health issues often requires a number of treatments and a difficult process of trial and error to find the treatment regimen that works best for each patient.
Once a doctor and patient have found the effective treatment or combination of treatments, patients must determine whether or not the treatments are covered by their insurer. After all this, the cost of treatment should never be a barrier to accessing care and should never be a reason for someone to drop out of treatment.
We urge lawmakers to prioritize meaningful prescription drug cost policies that would reform the current PBM reimbursement system and help reduce the costs that patients pay over the counter for their drugs. For some Californians, it’s a matter of life and death.
Cathryn Nacario is Executive Director of the National Alliance on Mental Illness San Diego and Imperial Counties.