After ProPublica reported on a Michigan insurer that wouldn’t cover a cancer patient’s last-chance treatment, a state lawmaker introduced a measure compelling health plans to cover a new generation of advanced cancer therapies.
Editor’s Commentary: It’s about time someone does something like this. I only wish it was being done at the federal level and it forced all insurance plans to cover life-saving drugs.
Overshare moment: ? I am on Medicare due to disability with Medicaid (state insurance) as secondary. Over 15 years ago I had emergency surgery to remove my appendix. When I woke up I was on a morphine drip. When I was in pain, I’d get a dose of morphine, fall asleep, and wake up in pain again. I wanted to be awake and not in pain!
I asked the nurses for anything other than morphine, so they gave me 2 of the opiate pain meds they were sending me home with. The day before, they wanted me to get up and walk but it hurt too much. After taking the pills I was sitting up in bed reading the newspaper and was up walking around. I felt that the medication had “cured” the depression and social anxiety I dealt with since a teen.
With that in mind, it’s easy to see why I became addicted to opiate pain medication and eventually, heroin. 10 years of heroin addiction and I was able to stop by using medication assisted treatment. After taking the medication for 3 years, an injection came out that lasts a month so I switched to that so I wouldn’t have to take the pills twice a day, and the way it slowly leaves your system makes it possible to stop it without withdrawals.
Well, I got a letter from my insurance yesterday saying they no longer cover the injection. So I just got an injection a month for a year with only a few shots left before I’m done, and now they want me to go back to taking the oral medication twice a day? Ruining my chance at being off of everything?
All of that to provide context to my point that insurance companies shouldn’t be allowed to just stop covering prescription drugs, and they shouldn’t be able to deny coverage of what a doctor is saying you need.
Here is ProPublica on how a lawmaker in Michigan wants state insurance to cover the latest cancer drugs.
ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.
Spurred by a ProPublica story about an insurer that denied coverage of the only therapy that could have saved the life of a 50-year-old father of two, a Michigan lawmaker plans to introduce a bill Tuesday requiring health plans in the state to cover cutting-edge cancer treatments.
In February 2020, Forrest VanPatten died fighting Priority Health, one of Michigan’s largest health insurers, over its refusal to pay for CAR-T cell therapy, his last-chance treatment. The therapy works by genetically reengineering patients’ own cells, then infusing them back into the body to beat back their disease.
Michigan has long required insurers to cover proven cancer treatments, but according to internal emails, some Priority Health executives argued that CAR-T was a gene therapy, not a drug, and thus not subject to the state’s coverage mandate.
State Sen. Jeff Irwin, D-Ann Arbor, plans to file the new bill to make explicit that Michigan’s cancer treatment coverage mandate includes a new generation of genetic and immunotherapies, including CAR-T.
Earlier this year, Michigan’s top insurance regulator told health plans they had to cover these treatments. Irwin’s measure would codify that guidance, ensuring it’s not dependent on one regulator’s interpretation of the law. He said he wanted the state’s requirements to be abundantly clear to both patients and insurers.
“I feel that the insurance company in this case was painting outside the lines,” Irwin said Monday in an interview. “This change that we’re making, I think, is going to make it hard to impossible for someone to make that same decision again around these particular treatments.”
The bill’s introduction was bittersweet for the VanPatten family. “If this helps any other family, any other person, we are all for it,” said Betty VanPatten, Forrest’s widow. “It just feels like they got one over on everybody.” Betty and her children said they hope Priority Health faces repercussions for the decision to deny coverage for Forrest’s treatment.
Priority Health’s decision not to pay for CAR-T cancer treatments was almost entirely motivated by the medication’s high cost, former employees told ProPublica. “It was, ‘This was really expensive, how do we stop payment?’” recalled Dr. John Fox, Priority Health’s associate chief medical officer at the time.
When the Food and Drug Administration approved the first CAR-T therapy in 2017, Fox tried unsuccessfully to persuade executives at Priority Health to cover it, citing Michigan’s law. He left his position with the health plan in 2019, in large part because he was disillusioned with the company’s decision not to pay for life-prolonging cancer therapies.
In an earlier statement to ProPublica, Priority Health said that “there was a lack of consensus in the medical community regarding the treatment” when it was first approved, and that the company began offering coverage after “extensive clinical work improved the treatment.” But well before VanPatten’s doctors requested Priority Health’s approval for the treatment in early 2020, an alliance of leading U.S. cancer treatment centers concluded there was substantial consensus about the treatment’s efficacy.
Asked about Irwin’s bill, Priority Health spokesperson Mark Geary said in a written statement that the company complies with all existing federal and state laws and has been providing coverage for CAR-T cell therapy for several years. “We also stand ready to continue to work with lawmakers and regulators in Michigan to find ways to offer Michiganders affordable access to effective, evidence-based treatments and procedures,” Geary wrote.
In the aftermath of ProPublica’s story, several Michigan lawmakers called out the state’s insurance department for not investigating Priority Health’s actions in the VanPatten case and failing to enforce the law that requires coverage of cancer drugs.
Regulators acknowledged they hadn’t cited a single Michigan insurer for violating the mandate since it was created in 1989.
Under existing law, the Michigan Department of Insurance and Financial Services can levy fines against insurers that fail to comply and can even suspend or revoke their licenses.
In an emailed statement, Communications Director Laura Hall said the agency anticipated backing Irwin’s proposal. The department, she wrote, “supports efforts to embed protections for cancer patients in state law.”
If Irwin’s proposal passes, not all Michigan health plans will have to follow it. Some employers pay directly for workers’ health care, hiring insurers to process claims. These plans are regulated by the federal government and are exempt from state coverage requirements, though some follow them voluntarily.
This article was originally published by ProPublica, and republished here under a Creative Commons license.