When it comes to health insurance reform, we don’t need Congress to reinvent the wheel. We need Congress to use some common sense to build on what’s already working and fix what isn’t. And on that front, my home state of Virginia’s General Assembly has been showing the way.
For the past several years, Virginia legislators have moved to reign in the insurance company practices that delay and deny doctor-prescribed care. Under Virginia law, state-regulated health plans already face limits on step therapy, the “fail-first” protocol that forces patients to try cheaper drugs before insurers will cover what their doctors actually prescribed, and the General Assembly is going further.
HB 2099, signed into law and taking effect in 2027, will require insurers to publish a list of services that need prior authorization, respond to urgent requests within 24 hours, and stop revoking approvals they’ve already granted.
But Virginia’s reforms can only go so far, because state law cannot reach federally regulated health plans. That is where Congress comes in. A good next step would be to pass the Safe Step Act (H.R. 5509), legislation that has been introduced (and reintroduced) in more than one Congress but never passed. It would solve one of the biggest problems with health insurance today by making it harder for insurers to delay or deny care that our doctors prescribe for us.
This issue is personal for me, as someone who has lived for more than twenty years with lupus, a chronic autoimmune disease. For the entire time that I’ve had to fight this disease, I’ve also had to fight my own health insurers who seemed determined to stand between me and the care that I needed.
It hasn’t been easy. After I was first diagnosed with lupus in 2004, it took some years for my doctor and I to learn what treatments worked best for me. But eventually, when we did seek approval for the immunosuppressant that could have stabilized my condition, the insurance company denied it over and over again.
Their reasoning behind the denials was as bureaucratic as could be: The treatment, which was effective against lupus, was designed originally to treat rheumatoid arthritis, and though I had been diagnosed with rheumatoid arthritis, it wasn’t my main condition; lupus was. So, according to my insurance company, the treatment shouldn’t be covered. That was my first experience with insurance that, far from providing access to care, blocked it instead.
Then, years later, after my condition worsened, my doctor thought it best to try a different medication, one that had been approved specifically for lupus. Surely, my insurer would have no problem covering this treatment, right? Wrong. My insurer denied this one, too. Twice. It was only after my doctor appealed and an outside organization stepped in to help with costs that I was finally able to begin treatment. Once the treatment began, I started to feel true relief for the first time in years. Yet even that was short-lived. Delays, coverage questions, and surprise costs kept resurfacing, making every infusion treatment feel uncertain.
I’m not alone in this experience, however. Through Lupus in Color, an organization I founded to support others living with this unpredictable disease, I’ve gotten to know many Virginians who’ve had similar experiences with their insurance companies. And the data show that millions of others have had run-ins with insurers that were glad to collect their premiums while refusing coverage for doctor-prescribed care. Of the roughly 4.9 million Virginians enrolled in private health insurance, only about 2.1 million are in state-regulated plans covered by Virginia’s step therapy law, according to KFF and the Agency for Healthcare Research and Quality. The other roughly 2.8 million are in federally regulated plans that Richmond cannot reach.
The Safe Step Act may not be a grandiose healthcare plan on the scale of the Affordable Care Act, but it’s what those 2.8 million Virginians need right now. If passed, it would curb the so-called “utilization management” practices, like step therapy or fail-first protocols, that are frustrating healthcare access for millions of American patients. Insurance companies use these practices to slow-walk and even outright deny our care. They’ve built their business models around saying “no,” but the Safe Step Act would curb many of these practices. It would force insurers to respect the doctor–patient relationship and prioritize what’s best for us, instead of what’s best for their bottom lines.
For patients like me, those protections would mean fewer gaps in care, fewer appeals, and more time focused on living instead of fighting insurers. For doctors, it would mean less red tape and more time spent practicing medicine. And for families, it would mean stability, safety, and a system that values health over profit.
Virginia has done its part. It’s time for Congress to do the same by passing the Safe Step Act and making health insurance work for the people it’s supposed to protect. And with roughly than six months left in the Congress’s term, the clock is ticking.
Racquel Dozier
Lupus Patient Advocate
Infusion Access Foundation Board Member
https://lupusincolor.com/