A customer walks along a pharmacy aisle. Photo by Mark Buckawicki via Wikimedia Commons
Rising health care costs continue to put treatment out of reach for vulnerable communities in San Diego and across California, including for many living with mental health challenges. Health care providers report a rise in anxiety, depression, and addiction due to the COVID-19 pandemic, economic fears, loss of work, rising cost of living, and many other factors.
Without meaningful efforts to address the cost of health care — and specifically what San Diego patients are paying at the pharmacy counter — we risk exacerbating a health crisis, as patients delay or forego treatment altogether.
A growing body of evidence suggests that the impact of onerous health costs is already negatively impacting the mental health of California patients and their families. A 2021 California Health Care Foundation poll found that more than half of Californians either skipped or postponed mental and physical health care due to cost.
And, according to a survey by the Kaiser Family Foundation, 57% of Californians reported they could not access the behavioral health care they needed.
California policymakers have made attempts over the years to improve what patients pay out-of-pocket for their medication, including through reform of the prescription drug rebate 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 rebates be passed on to consumers at the pharmacy counter.
Health insurance companies and PBMs negotiate significant rebates and discounts when purchasing medications from drug manufacturers. The price they pay after rebates is lower than the “list price” of the medicine. On average, pharmaceutical manufacturers rebate 40% of a medicine’s list price.
In 2020, the Department of Managed Health Care reported that health plans received more than $1.4 billion in rebates, up 57% from 2017. Due to a lack of transparency and accountability, nothing requires health insurance plans to make sure patients benefit from these rebates.
Passing SB 1361 would have helped lower patient out-of-pocket costs for their prescription drugs and helped to increase adherence to their treatment regimes. Unfortunately, California lawmakers were once again not able to reform the byzantine drug pricing and rebate system that health insurers and pharmacy middlemen use to drive profits on the backs of patients.
According to the San Diego County Health and Human Services Agency, around 1 in 4 San Diego County adults face a mental health challenge. Nationally, 1 in 5 adults experiences mental illness and 1 in 20 experiences serious mental illness, according to the National Alliance on Mental Illness.
Patients living with mental illness face a number of obstacles to successfully treating their conditions, including persistent stigma around mental illness and barriers to being properly diagnosed. Managing mental health conditions often requires a number of treatments and a challenging trial-and-error process to find what treatment regime works best for the individual patient.
Once a physician and patient have found the effective treatment or combination of treatments, patients must navigate whether or not the treatments are covered by their insurer. After all of that, the cost of treatment should never be an obstacle to accessing care and should never be a reason why someone abandons treatment.
We urge lawmakers to prioritize meaningful prescription drug cost policies that would reform the current PBM rebate system and help lower the costs that patients are paying at the counter for their medication. For some Californians, it is a matter of life and death.
Cathryn Nacario is executive director of the National Alliance on Mental Illness San Diego and Imperial Counties.