SPRINGFIELD, Ill. — A panel of Illinois lawmakers began hearing testimony Wednesday on Gov. JB Pritzker’s proposals for sweeping changes in the state’s health insurance industry.
The changes, which Pritzker first unveiled in his State of the State address in February, would limit the ability of companies to deny claims or steer patients toward cheaper, and possibly less effective, treatments. They are contained in an amendment to House Bill 5395.
They include banning prior authorization requirements for people to receive in-patient treatment at a psychiatric facility as well as all forms of so-called “step therapy” for prescription drug coverage. Step therapy refers to the practice of requiring a patient to try one or more cheaper, alternative medications before being allowed to access medications prescribed by their doctor.
Other changes in the plan include requiring insurance companies to publicly post the types of treatments and therapies that do require prior authorization; requiring them to maintain accurate lists of the providers who are in their networks; and banning the sale in Illinois of short-term, limited duration insurance plans that don’t meet the minimum standards under the federal Affordable Care Act.
Emily Miller, a senior advisor in Pritzker’s office, tried to assure the House Human Services Committee Wednesday that the administration was not waging war against the health insurance industry.
“Insurance has a role to play, and I'm not here to demonize the insurance industry,” she said. “I am here, though, to say that it is time for consumers to have a say in how insurance companies are administering their health care plans. And we want to make sure that consumers are protected.”
During the hearing, the committee heard personal stories from individual patients and their families, including some legislators, who spoke about their experiences having claims denied by their insurers.
Among them was state Sen. Patrick Joyce, D-Essex, whose son was born with a rare heart malfunction that requires treatments for which he needs prior authorizations. He also had a daughter who died following a long battle with leukemia.
“We had her stay four days in the hospital because we couldn't get a nausea medication that we knew worked after chemo (round) two,” he said. “We couldn't get it authorized in chemo (round) three. Very frustrating. Four days in the hospital, and I'm not sure how that saves somebody money.”
Dr. Mary Dobbins, a pediatrician and psychologist who is a past president of the Illinois Chapter of the American Academy of Pediatrics, testified about what she called a “mental health crisis” among children and youth in the United States. She said the crisis has been “artificially magnified by the requirements that tie up our time, our clinical time.”
“I've had multiple patients who destabilized because medicine they'd been doing well on was now denied, and the parents couldn't afford to pay for it out of pocket,” she said. “The appropriate level of care is commonly denied.”
But Lori Reimers, who represents the Pharmaceutical Care Management Association, a trade association for pharmacy benefit managers, argued that practices like step therapy and prior authorization requirements are important to control costs. Without them, she said, businesses couldn’t afford to offer health benefits to their employees.
“Insurance cards are not magic wands that simply make going to the hospital or going to the pharmacy more affordable,” she said. “There is incredible work in negotiating those costs between hospitals, physicians – both medical and behavioral – (and) drug manufacturers, all through a sophisticated and, yes, very complicated network of tools. Without these tools, costs cannot be negotiated down and eventually insurance is no longer attainable.”
Speaking at a news conference after the hearing, Pritzker brushed aside suggestions that his proposals would result in higher costs for consumers.
“Nobody's getting rid of broad cost controls here. That is not what this is about,” he said. “There are specific things – and we've done this before, this is not unusual – there are specific things where insurance companies are taking advantage of the power that they have. And we're simply saying, ‘You've got to be more reasonable,’ that there are situations in which you can't, and shouldn't, stop people from getting the health care that they need on the spot.”
The committee took no action Wednesday, but Chair Anna Moeller, D-Elgin, said the committee plans to hold more discussions and could vote as early as next week to advance the bill to the full House.
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