The Long History of House File 626

A deeper look at nonmedical prescription switching

This month, Iowa Governor Reynolds signed several critical pieces of mental healthcare legislation into law, including House File 626, an Act relating to continuity of care and nonmedical prescription switching by health carriers, health benefit plans, and utilization review organizations. This legislation has a long, contentious history at the Iowa Capital, dating back some six years.

Why was this bill important enough to lobby it year after year with no success? What exactly is nonmedical switching?

Nonmedical 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. This practice has been around for years, and patients have not had, until now, any control over it. In some cases, switching brands of medication for certain health conditions may go unnoticed by a patient, but when treating certain health conditions like epilepsy and mental illness, a forced medication change can be detrimental to patients, even catastrophic.

In 2022, the Alliance for Mental Health Care Access released a survey report, “The Dangers of Non-Medical Switching for Mental Health Patients,” and found that one third of surveyed patients were forced to pause, change, or completely 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, but with psychiatric care in particular, finding the “right” medication and dosage can take weeks, months, even years. Forcing patients to switch can lead to dire, life-threatening consequences. One fifth of patients forced to switch reported going to the hospital or emergency department because of side effects caused by the switch, like increased depression or anxiety, stress, and confusion, and negative impacts 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 and the consequences have been reported as far back as 2017, one year before I first helped lobby for this bill in Iowa.

A 2017 Stateline article “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 argument went ignored, and 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) that only temporarily stabilized her and caused noxious side effects like nausea, migraines, tremors, and vocal tics—all of which she never experienced on Pexeva. Stories like this are why mental healthcare 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 midyear 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 that 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 House File 626.

Knowing the potentially devastating effects nonmedical switching can have on psychiatric patients in particular, why then did preventative legislation take over six years to finally pass in Iowa?

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

They’ve been against this legislation every single year it’s gone to the capital, and many of our legislators are reticent to make insurance companies unhappy.

So what changed the tide this year?

This week I had the opportunity to chat with lifelong Iowan Threase Harms, President and CEO of Advocacy Strategies based in West Des Moines, and a state lobbyist with thirty years of experience representing clients like the Epilepsy Foundation of Iowa, Brain Injury Alliance of Iowa, and Easter Seals Iowa, just to name a few. Harms became involved in House File 626 over six years ago when the Epilepsy Foundation first brought up the issue of nonmedical switching and the detrimental effects on patients.

As Harms explains, doctors pick medications from a patient’s insurance formulary they think will best treat the patient’s condition, and when patients respond well to this carefully chosen medication, they in turn then 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 nonmedical switching bill was continually caught by PBMs and their unmoving position on “frozen formulary” legislation, which prohibits nonmedical 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 (picks an insurance plan that states it covers a certain medication), insurance companies should honor and uphold that contract, just as the customer has to.

In 2023, with support from several key legislators like Rep. Tom Moore (R), Rep. Gary Mohr (R), Rep. Dr. Megan Srinivas (D), and Rep. Brian Best (R), the Iowa House finally passed the nonmedical switching bill, but it ultimately died in the Senate. 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, Sen. Cherielynn Westrich (R) worked relentlessly for this bill after a negative personal experience with a nonmedical medication switch herself. Negotiations, Harms reported, continued to the bitter end with Senator Jeff Elder (R), a protector of insurers and PBMs and the biggest opposition to the bill, and the coalition finally made a compromise by amending the language to include only the contract year a patient has signed up for.

All this combined, after six years, finally passed House File 636, and Gov. Reynolds signed it into law this month.

Rep. Moore, who sponsored the bill for multiple years, noted during floor debate, “I’m just so happy to see this come to fruition, finally, after seven years.

When Rep. Srinivas (D-Polk), spoke on the house floor about the bill, 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 Sen. Westrich delivered closing remarks in support of the bill, 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 and 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 this bill, but persistence won the day. ~

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