One of the things that D.C. pundits like myself say about the persistent healthcare debate is that there’s no silver bullet. The myriad forces involved in delivering us miracle 21st-century treatments have woven a Byzantine network of red tape that makes those treatments unaffordable. There’s no one simple fix that can suddenly make healthcare good, fast, and cheap.
Of course that’s not to say we just shrug our legislative shoulders and give up. There’s more than enough inertia in Washington without us surrendering to the status quo of devastatingly expensive care and impossible bureaucracy. Which is why it’s been so refreshing to see the Safe Step Act. Introduced by Republican Rep. Rick Allen (GA-12), the bill promises a pro-market solution that allows patients to receive the treatment they need faster and less expensively without middleman interference.
Here’s the problem. So-called step therapy requires patients to try a cheaper drug (or drugs) first before their insurer will cover the one originally prescribed by their provider. Medications are grouped into “steps” that patients need to essentially walk up: before the insurer will pay for step 3 drugs, patients have to first cross steps 1 and 2 – even if the doctor said, “Hey, you need step 3 now!”
In principle, it’s not a terrible idea. Something that’s made healthcare more expensive is doctors prescribing an expensive MRI when an X-ray will do. So insurers insist step therapy keeps healthcare costs down. But there’s a problem: it’s not true with step therapy. Indeed, step therapy fuels higher costs and waste, with 87 percent of providers reporting it eats up more healthcare resources. For patients with chronic disease, out-of-pocket costs rose by 37 percent because they had to get more, unnecessary drugs before just getting the originally prescribed treatments.
When patients have to jump through hoops – or walk up steps – they lose time and money, with some needing to step into the emergency room: 42 percent of providers report a patient needing to visit the ER after an insurer-required first-choice drug didn't work, and 79 percent of patients say they absorb extra ER visits and out-of-pocket costs on top of the medication they were already paying for.
This is one of those penny-wise, pound-foolish scenarios where whatever an insurer may save by delaying the right treatment, it often gets destroyed by other costs.
Step therapy protocols eat up more time for providers. The average practice spends roughly 13 hours a week on prior authorization paperwork – nearly two full workdays.
And there are political consequences to allowing this step therapy nonsense to continue. According to a new poll, two-thirds of likely voters say step therapy drives up healthcare costs, and 90 percent of them say they trust their own doctor to decide the right medication rather than their insurance company.
So then the Safe Step Act, pardon the pun, steps in. This legislation would require an exceptions process that gives providers a clear, timely route to override step therapy when it doesn't fit a patient's medical needs. More than 40 states already require this process for state-regulated health plans.
Two good examples of this in action are Alaska and Kentucky. Alaska requires insurers to give patients and providers a clear, accessible way to request an exception to step therapy, and to cover the prescribed drug once one is granted. Kentucky, an early mover on step therapy reform, unanimously passed a bill in 2022 that grounds step therapy in accepted clinical guidelines and adds internal appeals and external review.
The Safe Step Act simply extends this process to employer health plans regulated under federal law that are out of the reach of state protections. It also keeps care decisions where they have always belonged: with the doctors who treat patients in their own practices. Versions of the Safe Step Act have earned broad support for multiple Congresses, yet Washington continues to surrender to the status quo. This is despite overwhelming political support. Of likely voters, 78 percent support the reforms in the Safe Step Act, according to one poll, including 75 percent of independents. Another poll found 57 percent of GOP voters more likely to back candidates who support these reforms and 66 percent opposing step therapy outright.
President Trump has demanded insurers cut red tape that puts barriers between patients and their treatments. But if Congress keeps letting insurers walk all over patients, these efforts will fall short.
Maybe there is a silver bullet. Maybe it’s time for Congress to finally step up and pass this.
Jared Whitley is a longtime D.C. politico, having worked in the US Senate, White House, and defense industry. He has an MBA from Hult Business School in Dubai. This year, the Society of Professional Journalists named him among the best columnists in the Intermountain West.
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