Protecting Health Access is a Continuous Endeavor

By Penn Quarter Partners  

Ongoing discussions around AI’s decision-making capacity as a health care tool, such as reports claiming it can be used to deny necessary health care to critically-ill patients, highlight the critical inflection point we stand in when it comes to access to care.

At Penn Quarter Partners, we know that protecting that access is anything but simple. Working with our clients — and, by extension, the patients they serve —we see health care access as a campaign that must be waged on the ground, at the federal level, and in the states, day by day.

That’s because barriers to care access can come in many forms, be they regulatory, legislative, or corporate business practices. And when those barriers are effectively implemented, the damage they incur hurts not only today’s patients but also tomorrow’s because curtailing adoption of new medical innovations discourages investment in further research and development.

While there have been some important battles won in strengthening access to care, including the recently-passed congressional legislation reforming pharmacy benefit manager (PBM) practices, there are always more barriers that must be addressed.

Here are three ongoing examples, from both the private and public sectors, that we observe and address in our day-by-day work in improving health care access.

Step Therapy

Under step therapy, medications prescribed by physicians for serious chronic illnesses may not be covered by the patient’s insurance provider until they first try insurer-preferred treatment options. This is also commonly referred to as “fail first” because the originally-prescribed medication won’t be approved until the patient “fails” with the first prescriptions.

As the patient advocacy organization Let My Doctors Describe describes it, these access restrictions “take the decision-making power out of the hands of you and your doctor…(they) put your health at risk, undermine your doctor’s expertise and cause significant financial waste in our health care system.” Patients, as documented in media reports, have had their health put at risk by these policies.

There is advocacy work taking place here, as legislation has been developed in both Washington and the states (and, in fact, passed in some states) that would, among other remedies, speed the process by which patients can change their medicines if the original insurer-approved prescription proves to be ineffective or cause adverse reactions.

Kidney Disease Medication Access 

Many kidney disease patients on dialysis require prescription medications known as phosphate-lowering therapies. Without these oral meds, patients can suffer severe health deterioration, facing a heightened risk of cardiovascular illness among other maladies.

Until 2025, patients could pick up these medicines at their local drugstore and have them covered by their Medicare Part D prescription drug coverage. A change implemented by the Centers for Medicare and Medicaid Services (CMS) in November of 2024 changed that, and placed the phosphate-lowering therapies in what is known as a Medicare “payment bundle,” essentially making them compete with other kidney disease products and services for a fixed pool of money. As a part of this change, the medicines must also be dispensed through dialysis centers rather than pharmacies.

As the American Association of Kidney Patients describes, this regulatory change has caused disruption and delays for patients already struggling with serious health conditions. It’s an access barrier with significant access consequences.

Penn Quarter Partners is working with advocates pressing for legislative or regulatory remedies to restore the access to these treatments upon which kidney patients could once depend.

Alzheimer’s Screening Coverage

With seven million Americans afflicted with Alzheimer’s disease and that number growing steadily, many could be helped by recently-developed blood-based screening for the disease. Medicare, however, doesn’t cover this important test.

As the National Minority Quality Forum put it in Health Affairs, “Despite revolutionary blood biomarker tests capable of identifying Alzheimer’s pathology decades before symptom onset…the U.S. Preventive Services Task Force has failed to prioritize Alzheimer’s screening, creating artificial barriers that extend periods of untreated biological disruption.”

This innovation in the science around Alzheimer’s disease could have outsized impact on when and how patients receive their diagnosis. Stakeholders in this community are working to advance congressional legislation that would create a pathway to coverage for this screening tool and Penn Quarter Partners is keeping close to the matter.

Accessibility is one of the most important factors in American health care.  Achieving and protecting it requires understanding how it is affected by what happens every day in Washington, D.C. offices and corporate boardrooms.  Access barriers will persist. So must the effort to achieve solutions.