Congressman Jake Auchincloss (D-MA) introduced the ACA Copay Cost and Affordability for Patients (CAP) Act to limit annual prescription drug cost-sharing for patients enrolled in health insurance plans through the ACA Marketplaces. Millions of Americans with ACA Marketplace coverage struggle to afford necessary medications, often facing thousands of dollars in out-of-pocket costs before reaching their plan's maximum limit.
A 2025 analysis by No Patient Left Behind found that health exchange plans have increased patients' prescription drug costs by an average of 36 percent since 2021. The same analysis estimated that 5.6% of enrollees had annual pharmacy out-of-pocket costs greater than $2,000, significantly higher than the $560.75 average in 2023.
The ACA Copay CAP Act would allow health plans to retain the majority of their plan benefit design flexibilities, while patients and taxpayers receive greater value from their premium subsidies and improved access to lifesaving medications.
The ACA Copay CAP Act would:
- Establish new out-of-pocket caps for prescription drugs:
- Starting in 2027, self-only coverage on the ACA would include a $2,000 cap per year for prescription drugs.
- Starting in 2027, family coverage on the ACA would include a $4,000 cap per year for prescription drugs.
- Increase the annual cap as premiums increase each year:
- Starting in 2028, the cap amount would increase each year based on the premium adjustment percentage set by the Secretary of Health and Human Services.
- Annual increases would be rounded down to the nearest $50 increment.
"Insurance doesn't work if the co-pays and deductibles are unaffordable," said Congressman Jake Auchincloss. "When people pay premiums to insurance companies, they should be able to trust that the insurer will cover them when a doctor prescribes a drug they need. My bill is a step towards repairing that trust."
"While Republicans fail to extend the Affordable Care Act premium tax credits for working families, Congressman Auchincloss is working to reduce the cost of health care in the ACA," said Darbin Wofford, Deputy Director of Health Care at Third Way. "Thanks to the Inflation Reduction Act, seniors now pay no more than $2,000 a year in out-of-pocket drug costs. Third Way applauds Congressman Auchincloss's introduction of the ACA Copay Costs and Affordability for Patients (CAP) Act to extend that same protection to people in the ACA Marketplaces."
"This bill will provide life-saving financial relief to millions of families. As prescription drug prices in the United States continue to spiral out of control, forcing families to choose between the medication they need and putting food on the table, Big Insurance's pharmacy benefit manager subsidiaries are profiting handsomely," said Wendell Potter, President of the Center for Health and Democracy and Founder of the Lower Out-of-Pockets NOW Coalition.
"Over the past decade, the seven largest publicly traded health insurers have reported more than $500 billion in profits, including $146 billion spent on stock buybacks—profits extracted in part from unaffordable cost-sharing requirements that patients face at the pharmacy counter., Health care should be about patients, not profits. Which is why Congress should advance this vital legislation without delay."
"Though ACA enrollment is up nearly 80% since 2021, too many health plans offer 'coverage' in name only. Prescription drugs comprise just 10 cents of every dollar spent on health care. Yet from 2021 to 2023, insurers increased pharmacy copay costs for the average enrollee by 36%, and 5.6% of people had more than $2,000 in annual drug costs," said Peter Rubin, Executive Director of No Patient Left Behind.
Patients and taxpayers expect premiums to pay for actual treatments. It is time to improve health plan quality. Thanks to Rep. Auchincloss and the ACA Copay CAP Act, we're one step closer to real truth in insurance by requiring health plans and their vertically integrated PBMs to provide meaningful consumer protections from unaffordable out-of-pocket drug costs."
The following organizations support the ACA Copay Cost and Affordability for Patients (CAP) Act: No Patient Left Behind, Third Way, Center for Health and Democracy, Grady Legal, PA, California Physicians Alliance, A Healthier WE, Health Action New Mexico, Triage Cancer, Courage California, Hemophilia Federation of America, Coalition of State Rheumatology Organizations, Arnall Golden Gregory LLC, Small Business Majority, Boomer Esiason Foundation, Doctors for America, Society of General Internal Medicine, Progressive Coders Network, and Patients Rising.
The full bill can be found HERE.
