Kennedy’s comments on AIDS — suggesting that gay men’s use of stimulants, rather than the HIV virus, were its cause — are troubling to Carl Schmid, executive director of the HIV+Hepatitis Policy Institute.
In a previous interview with Contagion, Carl Schmid, executive director of the HIV+Hepatitis Policy Institute discussed the federal courts 2022 decision on copay assistance, and the Biden administration’s decision to not enforce the court’s ruling. “I guess they’re getting pressure from the big insurers and the big PBMs. And you know what I’m hearing is that the insurers are saying this leads to higher drug prices. And you know, the Biden administration has really prided itself on taking on Big Pharma and lowering drug prices. Well, this is the perfect example to lower drug prices. And I don’t think they understand it,” Schmid said.
Carl Schmid, executive director of the HIV+Hepatitis Policy Institute, told Inside Health Policy excluding generics from the risk adjustment is fair because they are not a large cost to an insurance company in comparison to the branded drug. If generics were included, an insurer would receive credit for spending less money than another insurer providing a higher cost brand name long-acting drug. Schmid also noted that CMS is anticipating more people will be using branded PrEP than the less expensive generic alternatives, though new forms will be coming out and all insurers must cover the treatment at zero cost sharing.
The insurance companies fought us in court. We won, and they said we’re going to issue a new rule. Well, that was over a year ago. We thought it would be included, as well as define what cost sharing is and if copay assistance must count in terms of cost sharing. They could go the other way too and say that copay assistance can’t count. So they punted. They just said in the proposed rule that we’re going to issue a further rule regarding our case and the definition of cost sharing regarding patient manufacturer assistance to patients. We’re asking them to comply with the court order, and said that the 2020 rule is now in effect—that cost sharing must count for brand name drugs, except if there’s a generic alternative.
According to Carl Schmid, Executive Director of the HIV+Hepatitis Policy Institute, more vigorous enforcement would be a solution to discriminatory plan design. For example, in Texas, the Affordable Care Act guidelines are not enforced by the state insurance regulator but are enforced by the federal government. Moreover, the federal government constructs templates delineating ACA appropriate coverage guidelines for insurance plans to follow. Schmid explains that the templates in use are outdated, thus not reflecting current best practices. Hence, the federal government is not effectively engaging in enforcement.