Kali White VanBaale is an Iowa-based novelist, creative writing professor, and mental health care advocate. Find more of her work at kwhitevanbaale.substack.com (where this essay first appeared) and www.kaliwhite.com.     

This month, Governor Kim Reynolds signed several critical pieces of mental health care legislation, including House File 626, “an Act relating to continuity of care and non-medical prescription switching by health carriers, health benefit plans, and utilization review organizations.” This legislation has a long, contentious history at the Iowa capitol.

Why was this bill important enough to lobby for it year after year with no success? What exactly is non-medical switching?

Non-medical switching is when an insurance company forces patients to change their medication in the middle of a calendar year on the basis of cost. Insurers may stop coverage of a medication, ultimately forcing a patient to switch to an insurer’s “preferred” (i.e. cheaper) medication.

For years, Iowa patients have not had any control over that practice. In some cases, patients may not notice a switch to a different medication. But when treating certain health conditions like epilepsy and mental illness, a forced medication change can be detrimental to patients, even catastrophic.

HOW NON-MEDICAL SWITCHING HARMS PATIENTS

In 2022, the Alliance for Mental Health Care Access released a survey report, “The Dangers of Non-Medical Switching for Mental Health Patients.” The report found that one third of surveyed patients were forced to pause, change, or stop their mental health medication because their insurer stopped covering it in the middle of a calendar year, even when the patient had picked a specific plan that covered their specific medication during open enrollment.

For many patients, the right medication is imperative to managing illnesses and conditions like epilepsy. With psychiatric care in particular, finding the “right” medication and dosage can take weeks, months, even years. One-fifth of patients forced to switch reported going to the hospital or emergency department because of side effects caused by the switch, such as increased depression or anxiety, stress, and confusion, or negative impacts on other health conditions. Mental Health America reports that “health treatment is complex and studies show that medications in the same class for the treatment of mental illness are not interchangeable the way medications in other classes may be.”

This isn’t new information. The consequences have been known since at least 2017, one year before I first helped lobby for this bill in Iowa.

A 2017 Stateline article titled “New Rules Aim to Keep Patients on Medications That Work” profiled a Tennessee case of a then 12-year-old girl suffering from severe depression whose psychiatrist put her on the anti-depressant Pexeva. The girl responded well on the medication and was stable and healthy for four years. Then, her junior year of high school, her father’s employee health plan raised the price of Pexeva from $5 to $200 a month in the middle of a calendar year, which was too expensive for her family. Despite her psychiatrist’s arguments with the insurer and medical reason for prescribing that specific anti-depressant because of a family history of manic depression (Pexeva doesn’t trigger mania in patients with bipolar disorder), the girl was forced to switch to a less expensive antidepressant.

Within three weeks, the girl suffered her first manic episode with psychosis, and attempted suicide. She spent two weeks in a psychiatric ward as doctors tried a series of cheaper medications (approved by her insurance company), which only temporarily stabilized her. The new meds caused noxious side effects like nausea, migraines, tremors, and vocal tics—none of which she had ever experienced on Pexeva.

Stories like this are why mental health care advocates have fought for policies that prevent insurers from ceasing to cover a medication in the middle of a calendar year when a patient is still locked into a particular plan unless there is a true medical reason for doing so.

Insurers and the pharmaceutical industry have long argued that mid-year changes make it possible for them to give patients the “latest and most effective treatments, and allows them to offer patients alternatives when a pharmaceutical company suddenly raises the price of a particular drug.” Back in 2017, a spokesperson for the insurance company in the Tennessee case said the company’s decisions regarding adding or removing drugs from coverage are intended to help patients “take advantage of new clinical solutions and reduce their prescription drug spending while also enhancing patient safety,” and that her particular company was willing to “work with a customer’s doctor if there is a reason to consider approving coverage for a non-covered drug as medically necessary.” Contrary to what the patient—and her psychiatrist—reported.

Which brings me back to Iowa and House File 626.

INSURANCE COMPANIES AND PBMS BLOCKED ACTION FOR YEARS

Knowing the potentially devastating effects non-medical switching can have on psychiatric patients in particular, why did it take seven years for Iowa to enact preventative legislation?

I can tell you why from firsthand experience: insurance company lobbyists.

They’ve been against this concept every time similar legislation gas been introduced. Many of our state lawmakers are reluctant to make insurance companies unhappy.

So what changed the tide this year?

I recently had the opportunity to chat with lifelong Iowan Threase Harms, President and CEO of Advocacy Strategies based in West Des Moines. Harms has 30 years of experience as a state lobbyist representing clients including the Epilepsy Foundation of Iowa, Brain Injury Alliance of Iowa, and Easter Seals Iowa. She began lobbying for legislation like House File 626 more than six years ago when the Epilepsy Foundation first brought up the issue of non-medical switching and the detrimental effects on patients.

As Harms explained, doctors pick medications from a patient’s insurance formulary, which they think will best treat the patient’s condition. When patients respond well to this carefully chosen medication, they in turn select insurance plans they know will cover that drug. Mid-year medication switches without physician or patient control occur when Pharmacy Benefit Managers (PBMs) cut deals with drug manufacturers.

For the past six years, the proposed non-medical switching bill was continually caught by PBMs and their firm position on “frozen formulary” legislation, which prohibits non-medical switching for as long as the patient is on that plan, and the supposed additional costs it creates for insurers forced to pay those increased prices for multiple years. (I say “supposed” because the Stateline article also cites a study that showed these medication switches can create so many additional problems for patients that insurers still often end up paying more in the long run.)

But as Harms points out, at its core this practice isn’t fair or ethical. When a customer signs a contract with an insurance plan that states it covers a certain medication, insurance companies should honor and uphold that contract, just as the customer has to.

HOW THE TIDE TURNED

In 2023, with support from key legislators like Republican State Representatives Tom Moore, Gary Mohr, and Brian Best, and Democratic State Representative Megan Srinivas (a medical doctor), the Iowa House finally passed the non-medical switching bill. But the legislation never received a Senate subcommittee hearing.

In the interim, Harms said, coalition members worked tirelessly, holding conversations with physicians in their district, and changing the messaging of the bill to focus more on the unfairness to the patient, as I mentioned above.

On the Senate side this year, the floor manager, Republican State Senator Cherielynn Westrich, worked relentlessly for this bill after a negative personal experience with a non-medical medication switch herself. According to Harms, negotiations continued to the bitter end with Republican Senator Jeff Edler, a protector of insurers and PBMs and the biggest opponent. The coalition finally compromised by amending the language to include only the contract year a patient has signed up for.

The Senate unanimously approved the bill in April, and the House quickly agreed to the Senate amendment, sending the bill to the governor’s desk. Reynolds signed the legislation this month.

Moore, who had sponsored the bill for multiple years, noted during last month’s House debate, “I’m just so happy to see this come to fruition, finally, after seven years.”

When Srinivas spoke during last year’s House floor debate on House File 626, she said in part, “This is a really, really good bill. As a physician, I see the implications of having medical switches that are not necessary or even good for my patients every single day. This bill fixes that, and gives us a way to protect our patients and protect Iowans.”

And when Westrich delivered closing remarks in support of the bill in the Senate, she noted the bill finally gives patients an avenue to continue their medication. “This bill will help to promote stability of patients, improve health outcomes, and put doctors and patients in charge of their health care.”

Harms thinks the law is a good start with the compromise. Patients now have some protection, while the insurance companies some accountability. And it ultimately gets back to the market, as opposed to insurance companies controlling all levels, all the time.

It was a long road for House File 626, but persistence won the day.

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Top photo of two bottles of prescription medications is by WoodysPhotos, available via Shutterstock.