Disability Advocates Are Fighting a Dangerous Insurance Policy in the Midwest

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Step therapy, also known as a “fail-first” protocol, forces people to try and “fail” cheaper drug alternatives as an attempt to cut costs for insurers. But experts say it’s a physically, mentally, and financially exhausting process for patients.

It took seven years before Dantia MacDonald was able to get the right treatment for her mental illness.

Up until then, she had experienced persistent paranoia and delusions that led her to believe she wasn’t sick. After multiple hospitalizations, a stint in jail for a nuisance crime, and the loss of her career, MacDonald finally found relief in 2015 when she switched medications. Her symptoms subsided within three days.

This February, the Kansas resident and Medicaid recipient stood before the state senate public health and welfare committee and testified in favor of a bill challenging “step therapy,” a health insurance policy that would require her to try cheaper—and most likely less effective—drugs before she’d be able to take the medicine that actually made her better.

In a letter to the committee, MacDonald wrote that she would essentially lose Medicaid benefits if she married her partner—a heartbreaking reality that many disabled people in relationships face—and his insurance would require her to go through step therapy.

“I could lose another seven years of my life and end up costing the system much more money due to stays in psychiatric hospitals or even jail,” she wrote in the letter.

Step therapy, also known as a “fail-first” protocol, forces people to try and “fail” cheaper drug alternatives as an attempt to cut costs for insurers. But experts say it’s a physically, mentally, and financially exhausting process for patients, who essentially must prove that they actually need the medicine that works best for them.

Step therapy is a fairly common policy for both public and private health insurers. As of 2014, nearly 75 percent of large employers around the country reported offering employees health-care plans that use step therapy protocols, according to the American Journal of Managed Care. It can be complicated and lengthy: One September 2018 analysis by the journal Health Affairs found that, among 1,208 coverage decisions involving step therapy by 17 of the top commercial health insurers, 63 percent of decisions required patients to step through one drug, 37 percent required steps through multiple drugs, and 15 percent included at least three steps.

Although step therapy has an impact nationwide, activists are focusing on Kansas as a potential “target state” in the Midwest to pass step therapy-related reform. Although several neighboring states have passed step therapy-related reform, the state’s political tug-of-war on Medicaid expansion has stalled progress. Among Midwestern states, North Dakota, South Dakota, Michigan, and Nebraska have not established any step therapy reform or protections at all.

In some cases, step therapy does make sense, said Kari Ann Rinker, senior advocacy manager for the National Multiple Sclerosis Society who focuses on policy in Kansas, Missouri, and Oklahoma. For people who need antibiotics or have a temporary health issue, shifting to a generic medication may be an appropriate cost-saving method for both patients and insurers.

But for people with chronic illnesses and health conditions like diabetes, multiple sclerosis, or cancer, Rinker says, insurers that overwrite a doctor’s drug prescription can do more harm than good.

It can lead to more medical exams, more hospital visits, and higher health-care costs overall, since patients using the wrong medication—including people with mental illness, like MacDonald—may develop health complications that could have been avoided in the first place, says Sherrie Vaughn, executive director for the Kansas branch of the National Alliance on Mental Illness.

“If they can’t get the medications that they need to help them with their mental illness symptoms, then they’re not going to be able to function at the level that they want to,” said Vaughn, who is based in Topeka.

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