by Catherine Adkins
Across the Commonwealth of Virginia, people are experiencing burdensome barriers to access health care — particularly people like me who are battling chronic health conditions. My path to finding the right, long-term medicine to treat my diabetes was an arduous one. I worked with my doctor to try numerous options, but each was either ineffective from the outset or caused allergic reactions.
Finally, after failing on multiple medications, I found another alternative that kept my symptoms under control and allowed me to live a normal life. However, about a year before I was eligible to enroll in Medicare, my insurance carrier stopped offering plans in Virginia. I was forced to change plans because I had no other insurance options available to me. When I did, my new insurance refused to cover the new, effective medicine I needed unless I tried and failed on the other available options — a process known as step therapy or fail first.
The problem was, I had already failed on these medications — my doctor and I knew full well that, when I had been on the medications my insurance wanted me to take, they simply did not work. But my new insurance expected me to repeat this process all over again. My doctor’s office had to spend hours and a great deal of staff resources battling with insurance until they finally agreed to cover the medication, but not without a fight. Other drugs simply were not covered at all. Many Virginians with serious, chronic conditions, such as ALS or blood cancer, simply cannot afford delays when it comes to the treatments they need for their life-threatening conditions.
Step therapy was not the only barrier to care I have experienced. When I went on Medicare, I lost access to the only medication treating my high cholesterol. I had tried every single drug available on the market, and only one of them worked; for every other medication, even if it worked originally, I would develop flu-like symptoms and leg problems six months in, like clockwork.
When I started Medicare, I lost access to the financial help I had qualified for with private insurance.
My public-school teacher’s pension was just high enough to put me over the threshold, but far from what I would need to afford the medication that treated my symptoms. I have worked my whole life and have never asked for a handout to access my medications, I simply need a hand up to help me get there. I have a family history of high cholesterol so, despite trying to control it with a careful diet, there is not much I can do to keep my cholesterol down.
As difficult and frustrating as my situation is, it is far from unique. Patients across Virginia experience similar barriers to care and suffer health consequences from these impediments and delays as a result. Many of them are preventable. For example, numerous states have commonsense safeguards in place that protect patients like me from having to go through the step therapy requirement when a patient’s doctor already knows that patient has failed on that same medicine already; Virginia is not one of these states.
Some may argue that fail first policies are cost-savers. This makes no sense to me. How is it a cost savings to make me take a medication my doctor knows won’t work and that could potentially make my condition worse, leading to greater costs in the future?
The General Assembly took an important step and expanded the Medicaid program here in Virginia earlier this year. When the Assembly returns to session I hope they will continue to look for ways to improve health care costs and access to care for everyone.
Patients should not have to jump through hoops to get the care they need, regardless of the access issue in front of them. I urge legislators to pursue commonsense improvements for step therapy and other health care access issues. Let’s reduce the roadblocks to necessary medicines and treatments and help ensure nothing stands between Virginians and the care they need.
Adkins is a Danville resident and retired school teacher. She wrote this column for the Register & Bee.