A study published in 2022 found racial inequities in coverage denials for cancer patients. Black patients were nearly three times as likely to be denied.
BELLEVILLE, Illinois — Illinois Governor J.B. Pritzker’s plan to crack down on lengthy delays and coverage denials in the health insurance insurance industry sailed through the House of Representatives with bipartisan support last week, and it has "great momentum" heading into the Senate, he said at a Monday morning stop in Belleville.
The 168-page proposal would regulate the health insurance industry and require companies to grant speedier approval to medications or plans of care prescribed by physicians.
Doctors at the BJC Medical System hospital in Belleville said they have often run into snags or outright denials when attempting to prescribe certain medications to their patients.
"It’s extremely frustrating," Dr. Jennifer Neville said. "We have new clinical data for a certain class of medication that is actually originally prescribed for diabetes. But we found that it actually decreases cardiovascular events in patients with heart failure and decreases their risk of kidney disease. And insurance hands down denies these medications every time we prescribe them."
Neville said she often receives calls from cardiologists who ask her why she hasn’t tried using the drug to reduce a patient’s risk.
"I have to say that, ‘Yes, I’m aware of the recommendation, but insurance will not cover it,’" she said. "It’s an algorithm that [insurance companies] see a diabetes medication. And we haven’t tried a first-class medication like Metformin. And so that immediately kicks it back to us that it’s not covered. And we have to jump through those hoops."
She says those sorts of arbitrary administrative blockades can carry real risk for patients.
"They have an increased risk of cardiovascular disease and increased risk of hospitalizations for some medications," she said. "So literally being on this medication could decrease your chance of heart if they know heart or kidney issue, or possibly decreased chance of being admitted to the hospital."
Pritzker ramped up his rhetoric targeting greed in the insurance industry during his first stop on a statewide tour.
"Too often, utilization management results in a denial of coverage because insurance companies simply want to boost profits," the second-term governor said. "It’s an unhealthy and an unfair system for patients."
Under Pritzker’s proposal, this form of so-called ‘step therapy’ would be outlawed. Instead, insurance companies would have to defer to the doctor’s prescribed plan of care.
Lieutenant Governor Juliana Stratton (D-Illinois) made the trip with Pritzker and highlighted a 2022 study that showed racial inequities in coverage denials for cancer patients.
Research published in the International Journal of Environmental Research and Public Health found white cancer patients were denied coverage 3.8 percent of the time, while Hispanic patients were two-and-a-half times more likely to be denied coverage, and Black cancer patients nearly three times as likely to be denied.
"We hear our people’s pain, and we see the gaps that allow the pain to persist," Stratton said. "And we’ll do everything in our power to provide relief. We are quite literally laying down the law with private providers."
Illinois would also become the first state in the nation to clear prior authorization hurdles and ease access to mental health care for patients experience crisis situations during their first 72 hours in the hospital.
Springfield insiders took note of Pritzker’s pledge to spend his political capital to pass this proposal during his budget address in February. Many took it as a cue that Pritzker sees this as a major policy plank in a platform for higher office in four years.
State Senator Robert Peters (D-Chicago) traveled with Pritzker to promote the plan, and made repeated references to the pressure he’s under to deliver.
"We know that big time insurance companies are going to do whatever they can to fight back against against this bill," Peters said. "They’re gonna throw out everything, every scare tactic."
Lobbyists representing health insurance companies and the pharmaceutical industry opposed the regulations in the House. Their last stand in the Senate could come in the Insurance Committee where State Senator Napoleon Harris serves as chair.
The insurance industry has invested significantly in Harris’ political pursuits. According to 5 On Your Side’s review of public campaign finance records, the insurance lobby has given Harris’ campaign $197,750 since 2013. That accounts for more than 14% of all outside donations to his campaign, more money than any other industry.
Pritzker said he’s already spoken to Harris about the proposal and praised the Dixmoor legislator for "wanting to lift up particularly patients and those who may be suffering."
"So I’m anticipating actually his support for this bill," Pritzker said. "I’m hopeful that the people that are on the committee — or on the committees that will consider this — all understand that this is something that is very popular, it’s something that’s very important for the future of healthcare in the state of Illinois, and that it will pass one way or the other. And I’ve said, I’m not going to give up on this."
Senator Peters, who is carrying the measure through the Senate, echoed Pritzker’s suggestion that the bill could advance through another committee if it faces obstacles in the Insurance Committee.
"Whatever path, any path," Peters said. "Let’s just get it done."
The Illinois Senate Executive Committee has also handled large omnibus proposals, such as this one.
Harris was not available for an interview but sent a written statement through a spokesperson.
“I am a strong supporter of ensuring accessibility and availability to health care services in Illinois," Sen. Harris said. "If the Healthcare Protection Act comes before the Senate’s Insurance Committee, I’ll treat it fairly as I do with everything that comes before the committee. It is vital that affordable and quality health care is available for all Illinoisans.”
In past debates, insurance providers have argued that their cost-cutting efforts have served as guardrails against greed from hospitals and medical providers who might otherwise charge exorbitant amounts.
Pritzker pushed back against those claims and said his plan would reduce the need for bloated bureaucracies that hassle over approvals and denials.
He described "efficiencies that are brought on by a system that is more streamlined," and said his proposal "ultimately brings down health care costs for everybody."
"You won’t have to have as much personnel presumably on the insurance side to do this either, because we will have streamlined and made it more obvious what the treatment needs to be," Pritzker said. "It basically needs to follow the same guidelines that your doctor is following."
The proposal would also require health insurance providers to make regular updates to their coverage maps and provider lists to show patients an accurate read of doctors nearby. Existing law already imposes fines and fees on health insurance companies that don’t maintain adequate networks, but those doctor-patient ratios are often difficult to define geographically.
The Illinois Senate is scheduled to adjourn on May 24.
"I don’t think we’re going to have to go into another session in order to get this done," Pritzker said.
