Barriers to Patient-Focused Care: Step Therapy and Copay Accumulators

Almost 16 years ago, in March 2010, Congress passed the Affordable Care Act (ACA), which was then signed into law. While the legislation covered many healthcare issues, it included several important patient protections that received support from both major political parties. For the first time: 

• People could no longer be denied health insurance because of a pre-existing medical condition, helping those with the greatest healthcare needs to gain access to coverage. 

• Health plans could no longer place lifetime or annual limits on benefits, preventing patients with rare, chronic, or costly conditions from losing coverage after reaching a spending cap. 

• Young adults could remain on a parent or guardian’s health insurance plan until age 26, helping families manage healthcare costs during the transition into adulthood. 

• Insurance companies could no longer cancel a person’s coverage after they became seriously ill or received a new diagnosis. 

These protections were the result of years of advocacy from patients, caregivers, and healthcare organizations working to improve access to care. 

While this progress was significant, challenges still remain. In recent years, new insurance practices have emerged that can make it harder for people with rare and chronic conditions to access the treatments and care they need. Some policies fail to account for the unique needs of certain diseases, while others can create additional financial and administrative burdens for patients already managing serious health conditions. 

Advocacy continues to play an important role in addressing these barriers. Some of the most common and impactful challenges facing patients today are outlined below. 

Fail First or “Step” Therapy 

One of the most important parts of healthcare is the ability for a patient and their healthcare provider to work together to choose the treatment that is best for that individual’s needs. This is especially important when treating rare, complex, or life-threatening conditions. 

With step therapy, however, an insurance company can require a patient to try one or more lower-cost medications before approving the treatment originally prescribed by their healthcare provider. In other words, the patient must “fail” on those alternative treatments before gaining access to the recommended medication. 

This process can take weeks or even months, potentially delaying access to effective treatment while symptoms worsen or a disease progresses. In some cases, the required medications may not be the most current or appropriate treatment option for that patient’s condition. The process for determining when a patient can move on to the next treatment step can also vary widely. 

The bipartisan Safe Step Act (S. 2903/H.R. 5509) would establish safeguards to help ensure patient needs are considered. The legislation would improve transparency, require clearer communication, and allow healthcare providers to request exceptions when delaying access to the prescribed treatment could harm the patient. 

Additional information can be found here. 

Copay Accumulator or Maximizer Programs 

Many patients rely on financial assistance programs to help cover the cost of medications and healthcare services. This assistance may come from charities, nonprofit organizations, manufacturers, or other support programs. 

Under most health plans, the money paid toward a patient’s copays and other healthcare expenses counts toward their annual out-of-pocket maximum. Once that limit is reached, the patient generally does not have to pay additional covered healthcare costs for the rest of the year. 

Copay accumulator and maximizer programs change how those payments are counted. Under these programs, financial assistance provided by a third party may not count toward the patient’s out-of-pocket maximum. Only the money paid directly by the patient is applied. 

As a result, patients may face unexpected healthcare costs even after receiving financial assistance. This can make treatment less affordable and may force some individuals to delay, reduce, or stop care because of the added financial burden. 

The bipartisan HELP Copays Act (S. 864/H.R. 6423) would require insurers to count all eligible payments toward a patient’s annual out-of-pocket maximum, regardless of where the payment originated. 

Although court decisions have challenged these practices and new resources are available to help patients protect themselves, congressional action is still needed to permanently prevent these programs from creating barriers to care. 

Additional information can be found here. 

Prior Authorizations and Alternative Funding Programs 

Even as advocacy efforts continue to address step therapy and copay accumulator programs, new barriers to care are emerging. 

Prior authorization requirements often require healthcare providers to obtain approval from an insurance company before certain treatments, medications, or services can be covered. These reviews can create delays in care and add administrative burdens for both providers and patients. As insurers increasingly incorporate automated and AI-driven review processes, concerns have grown about inappropriate denials and additional obstacles to timely treatment. 

Alternative Funding Programs (AFPs) are another emerging issue. These programs can limit or complicate access to treatments for rare and serious conditions by shifting patients away from traditional coverage pathways and into alternative assistance arrangements that may not always meet their healthcare needs. 

Take Action 

Accessia Health is committed to elevating patient voices and advocating for policies that support access to affordable, patient-centered care. Through educational resources, policy updates, advocacy initiatives, and opportunities to engage with lawmakers, we work to help patients, caregivers, and advocates stay informed and involved in issues that affect healthcare access. 

There are many ways to make your voice heard. You can respond to advocacy action alerts, contact your elected officials, or share your healthcare experiences to help demonstrate the real-world impact of policies like step therapy, copay accumulators, prior authorization requirements, and other barriers to care. 

To stay informed about healthcare policy developments and advocacy opportunities, subscribe to Accessia Health’s Policy & Advocacy newsletter, or visit our Advocacy Action Center. 

Blog and legislative insights by Dane Christensen, Washington Representative with the Health and Medicine Council