Health insurance group CEO: Medical costs ‘at a tipping point’

High deductibles and copays. Exorbitant prices for certain prescription drugs. Surprise bills from out-of-network providers. Continuing efforts to kill the Affordable Care Act. No wonder that health care dominated the first Democratic presidential debates, with several candidates denouncing insurance companies. Matt Eyles, CEO of America’s Health Insurance Plans, the trade group representing leading health insurers, sat down recently with USA TODAY’s Editorial Board. Questions and answers have been edited for length and clarity.

Q. What’s the biggest challenge facing the U.S. health care system?

A. Cost and affordability. That’s really the biggest driver of a lot of the change and dissatisfaction with the health care system, in addition to some of the complexity that we see. I think we’re at a tipping point in terms of what we can afford both at a sort of systemic level and at an individual level.

Matt Eyles, CEO of America's Health Insurance Plans, answers questions from USA TODAY's Editorial Board on July 16, 2019.

Matt Eyles, CEO of America’s Health Insurance Plans, answers questions from USA TODAY’s Editorial Board on July 16, 2019. (Photo: Hannah Gaber/USA TODAY)

Q. How are high drug costs affecting health care premiums?

A. We’ve seen launch prices (for new drugs) continuing to go up and up. There’s no better example than what we’ve seen for oral anticancer agents, where the average price for a treatment is about $15,000 a month. We’ve seen price increases year after year. That’s really what’s fed a lot of the dissatisfaction. Something has to give. … Pharmaceuticals are now 23 cents on the dollar of every insurance premium, at least in the commercial market.

Q. What are some games drugmakers play to keep prices high?

A.Humira is the poster child for bad patent behavior. They’ve created a patent thicket or a patent fortress, whatever you want to call it, around Humira. As a result, that product will have been on the market in excess of 20 years by the time we might see a biosimilar. It would be much preferable to go to a date-certain period of market exclusivity, so that they’re not fighting in court over all of these patents.

Q. Do you have another example?

A. Allergan was trying to license its patent (for eye medication Restasis) through an Indian tribe and trying to claim sovereign immunity to protect themselves from generic competition for a product. I mean, those are the kinds of games that the current system is incentivizing that we need to just address and get rid of.

Q. Is it hard to find lawyers to take on Big Pharma?

A. Trying to find an intellectual property attorney is almost impossible for us because they’re all (working for) owned by pharmaceutical manufacturers. They’re all conflicted out. It’s like impossible for us to do it.

Q. How are people who don’t have employer-sponsored health care faring?

A. When you look at the individual market, most of the people today are getting subsidies that make the premiums affordable. But when you look at that group of individuals who are just beyond the subsidy level and up, they’re the people who are really facing probably the most difficult situation.

Matt Eyles, CEO of America's Health Insurance Plans, meets with USA TODAY's Editorial Board on July 16, 2019.

Matt Eyles, CEO of America’s Health Insurance Plans, meets with USA TODAY’s Editorial Board on July 16, 2019. (Photo: Hannah Gaber/USA TODAY)

Q. Congress eliminated the mandate that all individuals purchase health insurance or face a tax penalty. Are the Affordable Care Act exchanges sustainable without the individual mandate?

A. We’re left without the mandate, but the subsidies are still in place. They have provided some level of stability, but that doesn’t mean that the exchanges are in good shape. It’s sort of remarkable that the insurance markets have been as resilient as they have been and that they are in the condition that they are today. That’s not to say that they’re in great shape. They’re wobbly, but generally stable. Our goal is to find ways to make them work more effectively.

Q. The Trump administration and a group of Republican attorneys general are trying to get the courts to overturn all of the ACA now that the individual mandate has been stripped from it. What do you think about their legal argument?

A. The lower court decisions (to throw out the ACA) were misguided and wrong. We don’t think there’s any way that you could reasonably read that the entire law should be overturned as a result of the individual mandate being zeroed out. We’ve tried to really focus on educating the courts about the real-world implications about what it would mean to completely overturn the ACA.

Q. What are those implications?

A. So it’s not just about (coverage of) preexisting conditions; it would also affect Medicaid beneficiaries and the Medicaid expansion that states have gone through. That would take 20 million people essentially off of coverage

Q. What do you think the public wants?

A. People really do want to fix and improve the ACA and make it work better. They don’t want to see it totally undone. They don’t want to try and start from scratch, whether it be “Medicare for All” or another run at a repeal-and-replace effort. They really want to say, let’s find out how we can make coverage more affordable.

Q. A number of the Democrats running for president support Medicare for All.

A. What we’ve seen from many of the candidates are proposals that would essentially replace private insurance with a government-driven, government-operated option that would do away with private insurance. We think that would absolutely be the wrong approach for many reasons

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