A brief summary of the US health insurance/drug reimbursement...

A brief summary of the US health insurance/drug reimbursement system for those interested. It seems to be very complex and I'm sure I've barely scraped the surface.

There are three main funding sources for health care in the United States: the government, private health insurers and individuals.

Approximately 35% of the population has publicly funded healthcare coverage. The two main government funded healthcare schemes are Medicare and Medicaid. Medicare is primarily for people aged over 65 whereas Medicaid covers low income families and those with certain disabilities. Approximately 19% of the US population is covered by Medicaid.

Those ineligible for government health insurance acquire private health insurance through their or a family member's employer or by purchasing health insurance on their own. Roughly 66% of the population has private health insurance cover.

The remaining 9% of the population is uninsured.

The US government does not directly regulate or control the price of prescription drugs. There is no PBS in the US, with prescription drugs paid for through the various healthcare schemes.

Prescription drugs represented approximately 10% of total US healthcare spending of US$3.36 Tn in 2020.

Of the US$348 bn spent on prescription drugs in the United States in 2020, 40% was by private insurance, 32% by Medicare, 10% by Medicaid, 4% by other public insurance, 1% by other payers and 13% was out-of-pocket.

Eligibility for Medicaid is determined at the state level and roughly half of enrolees nationwide are children. Medicaid puts a limit on the number of prescriptions that are covered per enrolee and most states require prior authorization (PA) before granting coverage of specific medications. Medicaid programs typically require modest copayments for each prescription.

In order for states to receive federal Medicaid funding for prescription drugs, drug manufacturers are required to have a rebate agreement with the Secretary of Health and Human Services. Under the Affordable Care Act, the minimum rebate for innovator drugs is 23.1% of Average Manufacturer Price, or a minimum of 17.1% for drugs with only paediatric indications. Because the Medicaid rebate is based on prices paid in the private sector, manufacturers have an incentive to increase private sector prices.

For those with private health insurance, how prices are set and who gets what is complicated (see below)



The primary source of payment for trofinetide US Rett patients will be Medicaid and private health insurers and probably a combination of both. In the case of patients accessing Exondys 51 – the drug manufacturer, Sarepta, saw a 40% Medicaid/60% private health insurance claim breakdown.

https://www.vox.com/2014/4/30/18077...ree main funding,half of all medical spending.

https://www.chcf.org/publication/us-health-care-spending-who-pays/

https://www.census.gov/library/publications/2021/demo/p60-274.html

https://www.statista.com/statistics/200960/percentage-of-americans-covered-by-medicaid/

https://www.healthline.com/diabetes...pricing#Who-Really-Benefits-from-Drug-Rebates?

https://ojrd.biomedcentral.com/articles/10.1186/s13023-021-01943-w

https://www.ncbi.nlm.nih.gov/books/NBK56182/