How Virginia can lower health care costs without sacrificing access to critical medications

How Virginia can lower health care costs without sacrificing access to critical medications

Reducing health care costs is overwhelmingly supported by Virginians, and for the significant number of residents living with chronic and rare diseases, this issue is especially acute. Therefore, addressing health care access and affordability challenges remains a top priority for Virginia lawmakers during the 2024 General Assembly session.

Treating specific medical conditions, addressing high health care costs

A patient population affected by high health care costs: individuals with primary immunodeficiency (PI). Individuals with PI have one of over 450 rare disorders in which part of the body’s immune system is missing or not working properly. They are very susceptible to repeated, persistent and severe infections. Infections can lead to debilitating illnesses that require treatment with intravenous antibiotics and/or hospitalization, and some infections are fatal. A person with PI may also have autoimmune conditions such as irritable bowel syndrome, lupus, or rheumatoid arthritis. Finally, those with PI are at an increased risk of allergies and certain cancers, including lymphoma and leukemia. Fortunately, most people with PI can live healthy and productive lives if they receive lifelong immunoglobulin replacement therapy, an innovative and life-saving therapy derived from donated plasma.

In the last years, Virginia lawmakers have been trying to create a prescription drug affordability board (PDAB) and this year Senate Bill 274 AND House Bill 570 intend to do the same. The proposed board would consist of health care experts empowered to identify prescription drugs that pose affordability challenges for patients and mandate drug prices by setting payment caps. State PDABs are a growing national trend. At least eight states have established PDABs and other states are actively considering legislation to create them.

Bipartisan Supporters Pledge to Reinstate Virginia’s Prescription Drug Affordability Board in 2024

Although well-intentioned, many patient communities are expressing concerns about the unintended consequences these boards may have on access to critical medications. The goal of a PDAB is to reduce costs, but Virginians must ask who will see the savings, and more importantly, what is the impact on patients?

PDABs and their attempts to impose price caps could potentially threaten patient access by stifling investment in the research and development of innovative medicines that life-saving patients rely on. If pharmaceutical manufacturers face state-mandated payment limits, a negative impact can be expected not only on access to current drugs, but also on future investments in research and development. These unintended consequences are objectionable and should give caution to legislators in considering the creation of a PDAB.

The health insurance ecosystem is incredibly complex. While PDABs are focused on the list price and reimbursement rate of a particular drug, this does not necessarily relate to the out-of-pocket costs that patients are most concerned about. Out-of-pocket costs affect the family’s budget and ability to afford not only necessary medications, but also other essential expenses. No one should have to choose between what they pay at the pharmacy counter and putting food on the table.

Other necessary reforms

Virginia lawmakers have an opportunity to meaningfully address the high out-of-pocket costs patients continue to face — and that starts with reforming a growing industry of middlemen called pharmacy benefit managers (PBMs).

PBMs work with health insurance providers and have evolved into one of the most influential decision makers for health care access and affordability. PBMs dictate which drugs are covered by a health plan, what the out-of-pocket costs are, and whether patients and doctors must jump through additional hoops — such as prior authorization or step therapy — to access a drug. These tactics lead to significant delays in patient treatment, resulting in adverse health impacts, higher costs for consumers, and greater administrative burdens for providers. Thankfully, legislation has been introduced this year to address PBM practices, House Bill 1041. This measure will provide needed transparency in PBM practices and help pass the savings on to Virginians.

Additionally, Virginia legislators can look to members of Virginia’s congressional delegation who are leading efforts to prohibit harmful practices AND PBM address at the federal level.

Within the health policy space, there is considerable discussion of costs—costs for regulated and state-sponsored insurance plans, out-of-pocket costs for patients, costs for employers to provide health coverage, premium costs, and beyond. But let’s not forget about value; specifically, the value that comes from accessing life-enhancing and life-saving therapies. Also important is the value of being healthy enough to work and pursue our goals, to contribute to our communities, and the value of spending more time with our families and loved ones. These should be the goals of our health care system, and I encourage our legislators to keep this value in mind when debating these issues.

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