Early in the pandemic, Dr. Kathryn Nagel was working in a medical ICU in New Haven when a patient in his 30s was admitted with diabetic ketoacidosis, a deadly condition that occurs when there’s not enough insulin in the body.
The man had diabetes and needed insulin medication to manage it properly, but he had been rationing the supply he had left.
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“And the reason for this was because he had lost his job during the pandemic, and with his job loss, he lost his insurance,” Nagel said. “And with a list price of hundreds of dollars per vial, insulin became out of reach for him.”
Nagel, who has Type 1 diabetes herself and is policy lead for Connecticut #Insulin4All, told this story to members of the state Insurance and Real Estate Committee as she testified during a virtual public hearing in support of two health care-related bills that will be included in this month’s legislative special session.
One bill would make insulin more affordable by capping copays and expanding emergency dispensing. The other seeks to expand telehealth services during the COVID-19 pandemic. A majority of experts, advocates and members of the public spoke in support of these initiatives during the hearing.
A 2019 report from the Health Care Cost Institute, a nonprofit research organization, found that the average amount a patient spent in a year on insulin jumped from $2,864 to $5,705 in a four-year period.
The insulin legislation would cap the copay for a 30-day supply of the medication at $25, which is lower the $50 cap proposed in an earlier iteration of the bill unveiled in February. It’s also one of the smallest caps among states with similar laws.
The legislation would also cap the costs for other diabetes medications at $25 for a month’s supply, and $100 for equipment like glucose monitors, test strips, and needles for state-regulated insurance plans.
Kerri Orr, a Type 1 diabetic, said this will go a long way in helping people avoid making painful and dangerous decisions, like rationing insulin, because they struggle with the costs.
“You know, we didn’t ask for diabetes, we didn’t choose it,” she said. “But we choose to pay in order to stay alive.”
One in four patients with Type 1 or 2 diabetes has reported using less insulin due to high costs, according to survey results published in the Journal of American Medical Association by Yale researchers.
Diabetics have died as they ran out of medication, as was the case with Kevin Houdeshell, an Ohio resident who died in 2014 at 36 years old after he couldn’t get more insulin because his prescription expired over the New Year’s holiday.
The special session bill would make Connecticut the 20th state to pass a version of Kevin’s Law, which allows pharmacists to dispense emergency refills of insulin without a prescription.
Advocates said it’s a good start, but are disappointed that the legislation does not provide more broad support for people who are uninsured or undocumented. The original version in February proposed creating a state assistance program for these individuals, but it does not appear in the special session bill.
Minnesota recently passed a law that created a similar income-assistance program that requires participation from pharmaceutical companies. But the state is now facing a lawsuit from a drug trade organization challenging that part of the law.
“I think that we will definitely look next year at trying to mimic the provisions of that law in which we are requiring the companies that are selling this product for exorbitant prices to directly help those who are not able to afford it,” said Rep. Sean Scanlon, an author and sponsor of the insulin legislation.
Meanwhile, legislators are hoping to utilize the federal 340B program to help lower-income residents with costs. The program allows approved providers and patients to get medications at significantly reduced prices.
Health providers called it a great, but imperfect program that is tightly regulated and complicated to navigate.
Not everyone was on board with the legislation. Susan Halpin of the Connecticut Association of Health Plans said while insurers recognize the exorbitant costs for insulin, copay caps do not solve the root of the problem, which lies in pharmaceutical pricing.
“It spreads the cost across more people, and I can understand the appeal of that, but looking long term, we’re afraid that does more harm than good,” Halpin testified Tuesday.
Many insurance carriers, she said, have already added lower-cost insulin medications to their plans and they’ve done this by negotiating down prices with drug makers. Halpin said carriers are concerned that this legislation will limit their leverage in these negotiations in the future.
Expanding Telehealth During The Pandemic, And Beyond
Halpin, on behalf of the major insurance carriers in Connecticut, also testified against special session legislation that would expand telehealth, or telemedicine, access and services.
Early in the pandemic, states and the federal government temporarily loosened restrictions on telehealth, expanding the circumstances under which doctors and health providers could “see” patients remotely by audio phone calls or video calls.
Services were greatly expanded for people on public programs like Medicare and Medicaid. Health providers in Connecticut did not get reimbursed for Medicaid telehealth services prior to the pandemic, which Sara LeMaster said became problematic once stay-at-home orders were issued and in-person visits dropped off.
LeMaster is the manager of government relations and public policy at the Community Health Center Association of Connecticut and said patient interactions went back up once they were able to implement telehealth. And she wants to see it continue.
“Over time, it’s our hope that implementing telemedicine, especially for Medicaid patients, reduces health disparities by allowing more patients to access the care that they need,” LeMaster said.
Supporters called for more inclusion of audio-only telehealth visits to help patients who may lack wi-fi or the technological capabilities needed for types of video calls. In a draft of the bill, audio-only appointments can only be done if the health provider is in-network.
The legislation also requires insurers to continue paying providers the same amount for a telehealth visit as they would for an in-person visit, which is known as payment parity.
Halpin said there isn’t enough data on the effectiveness of telehealth services to support these expansions, which would end on June 30, 2021.
“We know the prevalence [of telehealth visits] has increased astronomically, which may be a good thing or it may be a bad thing,” she said.
Halpin said many insurers are voluntarily providing parity pay during the pandemic, but do not want it codified in legislation. She said these proposals also come as health insurers approach the deadline to file 2021 rates for approval to the state Insurance Department.
“Passage of a mandate at this point while carriers are doing this voluntarily will throw that into a little bit of chaos and would require restructuring benefit packages, repricing rates and then re-submitting those to the department,” she said.
But the majority of people who testified Tuesday were in favor of expanding telehealth services, including many who said they would like to see some of these changes permanently adopted by the legislature.