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

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

Treating special medical conditions, addressing high health care costs

One patient population impacted by high health care costs: individuals with primary immunodeficiency (PI). Individuals with PI have one of the over 450 rare disorders in which part of the body’s immune system is missing or does not function correctly. They are highly susceptible to recurrent, persistent and severe infections. The infections can lead to debilitating illnesses that must be treated with intravenous antibiotics and/or hospitalization, and some infections are fatal. A person with PI may also have autoimmune conditions like 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, productive lives if they receive lifelong immunoglobulin replacement therapy, an innovative and lifesaving therapy derived from donated plasma.

In recent years, Virginia lawmakers have attempted to establish a prescription drug affordability board (PDAB) and this year’s Senate Bill 274 and House Bill 570 intend to do the same. The proposed board would be made up of healthcare experts empowered to identify prescription drugs that pose affordability challenges for patients and mandate drug prices by setting upper payment limits. State PDABs are a growing national trend. At least eight states have established PDABs and additional states are actively considering legislation to create them.

Bipartisan backers pledge to reintroduce Virginia Prescription Drug Affordability Board in 2024

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

PDABs and their efforts to impose price limits could potentially threaten patient access by stifling investment in researching and developing innovative, life saving medicines patients rely on. If pharmaceutical manufacturers are faced with state-mandated payment limits, one can expect a negative impact not only on access to current medications but also on future investment in research and development. These unintended consequences are objectionable and should provide caution to lawmakers 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 isn’t necessarily related to the out-of-pocket costs patients are most concerned about. Out-of-pocket costs impact a family’s budget and ability to afford not only necessary medication but other essential expenses. No one should have to choose between what they pay at the pharmacy counter and putting food on the table.

Other needed reforms

Virginia lawmakers have an opportunity to meaningfully address high out-of-pocket costs that 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 healthcare access and affordability. PBMs dictate which medications 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 treatment for patients, 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 necessary transparency in PBM practices and help pass savings on to Virginians. 

Additionally, Virginia lawmakers can look to members of Virginia’s congressional delegation, who are leading efforts to ban harmful practices and address PBMs at the federal level.

Within the health policy space, there is considerable discussion on costs – costs to state-regulated and state-sponsored insurance plans, out-of-pocket costs to patients, costs for employers to provide health coverage, costs of premiums, and beyond. But let us not forget about value; specifically,the value that comes from accessing life-enhancing and life-saving therapies. Also important are 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 healthcare system and I encourage our lawmakers to keep this value in mind when debating these issues.