Pre-Existing Conditions: Coverage begins fight for access

For too long, patients have been at the mercy of insurance companies, which could deny patients coverage based on pre-existing conditions.

Patients with pre-existing conditions thought our troubles were over with the Affordable Care Act.  Under this law, they could no longer deny coverage to patients based on pre-existing conditions. The law was supposed to provide healthcare and insurance coverage to those who could not afford it.

But, insurance is big business, and when the Affordable Care Act went into full swing in 2014, some insurance giants went on the offensive to cut costs and boost profits at the expense of patients with pre-existing conditions.

Insurance Companies Target Pre-Existing Conditions

It shouldn’t surprise anyone that insurance companies have tried to use loopholes to deny patients access to treatments they should be entitled to. This really scares me. I came from the era where you had to wait a year to get treatment if you had a pre-existing condition. I don’t want to go back there again.

Insurance companies’ latest tactic is to ration certain aspects of healthcare. This is specifically the case when it comes to prescription drugs. There have been breakthroughs in specialty drugs, using the latest in scientific advancements, such as biotechnology and living organisms.

Naturally, these drugs are more expensive because they are cutting-edge. They also have the potential to significantly improve the lives of people suffering from psoriasis, psoriatic arthritis, cancers and heart disease. Despite clear evidence of a treatment’s effectiveness, insurance companies are finding new ways to restrict coverage in an effort to protect their bottom line.

This is troubling for me and others who are desperate for a better quality of life while suffering from our diseases.

Pre-Existing Conditions Insurance Barrier: Step Therapy

Step therapy is a common insurance barrier to access for patients with pre-existing conditions.An example of this healthcare rationing is something called “step therapy,” or what’s also known as “fail first.” This insurance barrier to access requires patients to take a less expensive approach to prescription medications and then, as needed, graduate or step up to more expensive medications in the event the other, less expensive treatments aren’t working.

Insurance companies say that “fail first” policies protect save money by requiring the insured patient to try less costly medications first before being prescribed the most expensive medication. The reason that this is troubling to me is because the insurance companies are acting like doctors. Instead of allowing the recommended newer treatment that is available, they’re requiring patients to try older medications simply because they are less expensive.

Why is this dangerous?

Blocking the best, most relevant treatments for patients could be making our condition worse, or stifling any progress that has been made. It can be devastating and irreversible for patients. In one case, a patient who was denied her doctor’s prescribed medication became blind after being forced to try other less expensive drugs.

Many patients are being denied new advancements in treatments that are more effective and better for us, simply because the insurance company wants us them to try other drugs. No patient should ever be denied treatment of any kind or have to stop their current treatment because the insurance doesn’t want to pay for it.

Pre-Existing Conditions Insurance Barrier: Qualifying Method

Another method of regulating or limiting access to new medications insurance companies have used is the qualifying method. This means you must meet the qualifications for certain drug prescriptions before you can get them covered.

This barrier to access is a big problem for patients with pre-existing conditions like arthritis. The arthritic condition can be debilitating and limit mobility entirely. Yet, the insurance companies are not looking at the bigger picture of pain reduction and management. Many sufferers with arthritis are forced to continue treatment with older medications that provide some relief but not enough to improve daily quality of living. Since the less expensive drug helped slightly, the insured wasn’t allowed or didn’t qualify for the newer treatments that could have provided better results and much more relief for the patient.

There are biologic medications that work much better for us, but are extremely expensive when looked at the overall costs. This is one of the main reasons insurance companies are denying claims, because they feel if the patient responds to the less expensive medication there will be no need switch medications. This is not acceptable to people who are searching for the latest technology to help us recover.

No matter where we end up with health care reform, we need to remember our end goal: to get patients the health care that they need –when they need it. We can’t come up short for patients with pre-existing conditions. Patients with pre-existing conditions need to be given access to the right treatments.

What’s the point of providing coverage if insurance companies create barriers when it comes time to access care?

Watch: Diane’s Story

You’ll receive updates about new resources, patient stories and insights, advocacy work, and alerts about patient-support events.

The latest about patient advocacy

Join our Email List

Get notified about new stories and resources to empower patients and caregivers.