医疗保健法律和政策是数百万美国关节炎患者能否得到必要的治疗以控制他们的疾病并充分生活的关键。对一些人来说，这可能意味着行走和坐轮椅的区别，就业和残疾的区别，甚至是生与死的区别。
And although the U.S. Congress is at an impasse, states’ legislatures are taking action to protect and promote access to care and medications – including those for people with arthritis.
“With the gridlock in Congress, it could take years for federal legislation to move on many of the issues related to access to medications and care,” says Mark Guimond, director of state legislative affairs for the Arthritis Foundation. “States are not waiting. Some states can consider and enact a new law in just a few short months.”
So why does state legislation carry so much weight? For starters, most of the specifics of health insurance plans are governed by state law, so the laws in your state directly affect your access to care. For example, state laws define out-of-pocket drug costs and whether insurance covers an adequate network of health care facilities and doctors.
That is why the Arthritis Foundation and its volunteer advocates regularly work with state legislators and policy makers. The Foundation helps identify challenges, and volunteers share first-hand experiences. Together, they create a compelling lobby for the 52 million adults and 300,000 children in the U.S. with doctor-diagnosed arthritis.
“Using our motivated volunteer advocates to serve as citizen lobbyists is giving us the power to enact laws in state after state that limit the out-of-pocket costs on medications, reduce wait times for insurers to authorize specialty medications and many other benefits,” says Guimond.
Our Key Advocacy Priorities
以下是该基金会在州级为帮助关节炎患者支付药物和获得他们需要的治疗而努力的关键问题。
Out-of-Pocket Drug Costs
Insurance companies are implementing “specialty tiers” – a category in their drug formulary that shifts a greater proportion of the costs of expensive drugs, such as biologics, to patients. What’s more, many people with arthritis have additional conditions for which they need medication.
Why it’s important: This can add up to hundreds of dollars out of pocket every month – and even more in the first months of an insurance plan’s year for those trying to meet their deductible. The expense can potentially push some patients to go without critical medications.
Advocacy action:该基金会支持立法限制每月的共同保险费用，并在一年内分摊免赔费用。该法案将扣除费用分成12等额支付。在另一种选择中，它将把每一种药物的共同支付或共同保险限制在每月150美元。这些措施尤其可以帮助那些难以一次性获得全额免赔额和共付医疗费的患者。
New Drugs
A new generation of drugs based on existing biologics, known as “biosimilars,” is making its way to the U.S. marketplace.
重要原因:这些药物有望改善人们获得改变生活的药物的机会。但与合成仿制药不同的是，生物仿制药是从活细胞中的蛋白质中开发出来的。这使得它们更加复杂，难以复制。
Advocacy action:The Arthritis Foundation is a member of an important coalition focused on ensuring patients’ access to biologics and biosimilars, and ensuring biosimilars have distinct names to prevent confusion. It also is working to ensure that a doctor can prescribe a biologic rather than a biosimilar, when appropriate, so insurance companies do not make treatment decisions.
Understanding Costs
Patients shopping for health insurance can review an insurance plan on the company’s website, which typically shows whether a medication or service is covered. What isn’t shown is what the patient will actually pay.
Why it’s important: Patients shopping for health insurance need formulary transparency – the ability
to find out whether a plan covers the therapies they need, their out-of-pocket costs and how the coverage compares in other plans.
Advocacy action:The Foundation supports legislation requiring a “window-shopping approach” for patients to compare costs based on their conditions and treatments. This apples-to-apples comparison of plans and drug costs lets people make informed decisions when buying insurance.
Step Therapy / “Fail-First”
Insurers commonly require patients to try cheaper drugs before approving a more expensive prescribed medication. That may happen if the patient switches insurance plans or the insurer changes its prescription coverage.
Why it’s important: A patient’s condition might worsen while trying a drug that isn’t as effective as one that’s been proven to work.
Advocacy action:该基金会支持立法对这些政策进行限制，限制它们的时间限制，并允许医生推翻它们，这样病人就可以继续服用有效的药物。
Insurance Authorization
Insurers often take an unreasonable period of time to review a prescribed treatment before approving certain specialty drugs for a patient.
Why it’s important: This prior authorization delays treatment, potentially allowing the condition to worsen and putting the patient at risk. Some policies allow up to 15 days for preauthorization, and up to three days for life-threatening and emergency treatments. Even then, the insurer still could deny it, creating more delays and risks for the patient. And although a patient may appeal the denial, some appeals can be long and arduous and further delay treatment.
Advocacy action: The Foundation supports legislation that requires shorter, more reasonable review periods and less administrative burden for a patient to get approval for their medication or treatment.
Narrow Networks
In some cases, people buy insurance plans and then find that it has a “narrow,” or inadequate, provider network. That can happen if, for example, listed doctors aren’t taking new patients, specialists are not in the plan’s network or the nearest in-network hospital is hours away.
Why it’s important: Without ready access to doctors and hospitals, patients may be forced to use out-of-network providers at a much higher cost.
Advocacy action:基金会正在与这一新的战斗，以确保关节炎患者有及时的，合格的和地理上可获得的护理，从足够数量的医生，设施和服务，并适当涵盖在他们的保险计划。它正在与联盟伙伴合作开发可以提交给各州采用的语言。