Copay accumulators aren’t welcome in Virginia. As of this March, state legislators in both the state and its neighbor, West Virginia, passed legislation that requires insurers to count copay assistance cards and manufacturer-provided coupons towards patients’ out-of-pocket limits. This measure comes in direct response to insurers’ increased tendency to use the policies to prevent payment assistance from counting towards their enrollees’ deductibles. Truth be told, the bans aren’t all that surprising; since first gaining popularity in 2018, copay accumulators have faced blistering criticism from patient advocacy groups. One such organization, Patients Rising Now, lambasted accumulators in an article for Modern Healthcare, calling them “a discriminatory practice that limits access to needed medicines.”


The organization isn’t wrong. Copay accumulators can have a significant impact on a patient’s ability to afford needed medications. Consider the case of Mary Hawley, a senior who was interviewed by the Los Angeles Times after finding out that the manufacturer-provided coupons she received to limit the cost of her arthritis medication would no longer count towards her $6,000+ annual deductible. Previously, the coupons guaranteed that she would meet her deductible in a matter of months — but when those coupons stopped counting, she found herself wholly responsible for paying every medical expense. Short of encountering a massive medical emergency, she had no means of meeting her deductible — and her insurer, therefore, had no obligation to pay any claims.  


For a senior with health problems, the sudden financial pressure was stifling — and unnecessary. “It seems unfair,” Hawley told reporters for the Times. “It shouldn’t matter to them who’s paying my deductible, as long as it’s being paid.”


It’s easy to see the patient’s perspective here. They suddenly face painfully high drug costs, while the insurer appears to benefit twice: first by receiving a payment from the drug manufacturer, and second by leaving the lion’s share of payment responsibility on the patient’s shoulders. According to a report published by the PAN Foundation, when patients with copay cards or discounts are prevented from applying that assistance towards their out-of-pocket responsibility, they end up paying out similar amounts to those who lack the aid altogether.


Moreover, the weight of that responsibility can be dangerous if left unsupported. Given that co-pay cards and discounts are predominantly offered to underinsured patients on private plans, these added costs can make affording necessary medications all but impossible for some patients. The added financial strain can lead patients to stop treatment, stretch dosages, or decide between their health and necessities like food or rent. This, in turn, can result in worse patient outcomes; one 2004 study found that with some disease conditions, over 40% of patients can “sustain significant risks” by not following healthcare advice.


Co-pay accumulators could have a real impact on patients’ lives and health, and it seems clear that the bans put into place by Virginia and West Virginia were wholly necessary. But at the same time, it also would be unfair to point the blame entirely towards insurers. As unthinkable as it might seem, insurers do have a valid argument for doing this. As unthinkable as it might seem, plan managers do have a valid argument for writing copay accumulators into their contracts. In the above article for the Times, America’s Health Insurance Plans spokeswoman Cathryn Donaldson upbraids manufacturer-provided coupons as “a marketing scheme leveraged by Big Pharma to keep drug costs high for everyone.”


“The true issue remains that drug pricing continues to skyrocket,” Donaldson goes on to say, “with no clear explanation on how those prices are set.”


She has a point. Coupons don’t go out to everyone — and even for the underinsured, they may only mask the problem. Let’s return to Mary Hawley for a moment. The medication that she uses to treat her rheumatoid arthritis, Humira, costs over $38,000 per year on the retail market. With a coupon, she pays just $5 a dose. If that doesn’t hide the true cost of the drug, I’m not sure what would.


Here’s the most uncomfortable part of this whole mess: copay accumulators might be working to draw down prices. In June of last year, Reuters published the results of an analysis that considered the impact accumulator policies might be having on drug prices overall. Researchers found that “real U.S. drug prices, including discounts and rebates, fell 5.6 percent in the first quarter of this year, compared to a 1.7 percent drop in the same period a year ago.” The report’s analysts attributed the majority of the decline to copay accumulators and further commented that “if drugmakers cannot find a way to circumvent these programs by next year, those declines could double or triple.”


In a time when drug prices are at sky-high levels, these findings are striking — and inflect the bans in Virginia and West Virginia with a slightly more nuanced light.


Co-pay accumulators are harmful to patients. They increase out-of-pocket costs, threaten health outcomes, and impose unfair financial burdens on underserved patients — and for that, they needed to be banned. But in their absence, prices continue to elevate; manufacturer-provided coupons continue to mask the gravity of our drug cost problem. The issue at hand isn’t copay accumulators, not really. It’s the underlying prices they reveal. Frankly, the accumulator saga is a little disheartening — and it implores us to find a way to lower health care prices without inadvertently hurting the very patients that care is meant to serve.


We need to do a better job.