Fox attempted to revive the lie that the Affordable Care Act contains health care rationing in the form of “death panels” by pushing misleading claims about the law's prescription drug coverage.
On Fox's Special Report, guest host Doug McKelway asked the show's panel about a provision in the ACA that he claimed “is drastically limiting the availability of some drugs.” Fox contributor Stephen Hayes claimed “patients with diseases and conditions that require medication not approved by Washington bureaucrats” may “have to go without it with potentially very serious implications.” McKelway asked if the prescription drug provisions were “rationing or, as some people have said, the so-called death panels.” Fox contributor Charles Krauthammer concluded: “We're learning how much rationing is the essence of Obamacare -- the rationing of doctors, the rationing of hospitals. Here we begin to understand the rationing of drugs. Next, and in the end, will be rationing of care.”
Fox's description of the ACA's prescription drug coverage is misleading, and McKelway's “death panel” reference is outright irresponsible. The reality is that the way the ACA treats prescription drug coverage is in line with how private insurance companies have handled coverage for years.
Although Fox omitted it from its coverage, the ACA actually expands prescription drug coverage, including it as one of the 10 essential health benefits that all plans must provide. But just like the vast majority of currently offered health plans, plans offered under the ACA's health care exchanges will not provide full coverage to every prescription drug. These plans will be offered along with what's known as a drug formulary, a guide to what drugs the plan covers and how they cover it. As Think Progress' Igor Volsky pointed out, the use of a drug formulary is standard practice among health care plans:
Under the law, insurers must offer drug benefits as part of 10 essential health care benefits, meaning that millions of uninsured Americans will now have drug coverage for the very first time. But the coverage won't be limitless. Insurers will continue to rely on drug formularies -- as they currently do in the private market and Medicare Part D -- to decide which prescriptions are covered and which are not.
The ACA requires that issuers provide the greater of one drug from each category or class, or offer as many drugs in each category as are covered by a benchmark plan. The law allows states the choice of four different benchmarks, which Gottlieb helpfully lists in his article: 1) One of the three largest small group plans in the state by enrollment; 2) one of the three largest state employee health plans by enrollment; 3) one of the three largest federal employee health plan options by enrollment; or 4) the largest HMO plan offered in the state's commercial market by enrollment.
States -- not the federal government -- select the benchmark and insurers then offer coverage for the drugs listed in those formularies. “What the vast majority of states have chosen is a common small business plan, so you know it's saying what will be available in the exchanges and in the individual market generally is what's popular among small businesses now and that seems like a reasonable place to start,” the Kaiser Family Foundation's Larry Levitt explained.
The law also has provisions for people who rely on a drug that isn't covered by their plan's formulary. Patients can apply for exceptions in the case of medical need:
What if a drug I take is not on the list?
Your doctor can ask for an exception for medical need so that the insurer will cover it. The Centers for Medicare and Medicaid Services is encouraging insurers to respond to such requests within three days. If your request is denied, you can go through your state's appeals process, which usually is handled by insurance regulators. If you still can't get coverage and need to take the drug, you'll have to bear the full cost out of pocket, as it won't count toward your deductible or your co-insurance maximum.