Why Isn't My Medication Covered by Insurance?

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The medical profession in this country delivers excellent care in this country, although the quality is uneven.  Sadly and unfairly, the quality of medical care often depends upon one’s zip code.  Many Americans are underinsured and there are still many folks – including working people – who do not have medical insurance.  As I feel that health care is a right, employment should not be a prerequisite for insurance eligibility.  One should not be forced to remain at a job from fear of losing medical benefits. Racial disparities in medicine have been well documented.  And while medical professionals are plentiful in urban areas, residents who live elsewhere do not enjoy the same access, particularly to high-level specialty care.  Drug prices are often out of reach even when they are ‘covered’ by insurance.  And underlying this, physicians are under more pressure than ever, a reality that can’t be fully compartmentalized from their patients.

While we celebrate medicine’s amazing and emerging accomplishments for humanity, the rising tide has not lifted all boats.

Some boats are left behind.

I’ll offer one personal example of the medical profession’s underbelly.

I take care of many individuals with microscopic colitis, which is best treated with a drug called budesonide.  The therapeutic alternatives are much less effective.  Depending upon the patient’s insurance coverage, a month of this medicine is either highly affordable or is more expensive than the patient’s mortgage payment.  When it’s not covered, then the patient will have to struggle along using inferior alternatives.

So, when I’m poised to recommend this drug, I hold back.  I then ask the patient to inquire from his insurance company what the cost of budesonide would be.  Every time this issue arises, it grates me that that are cracks and fissures in the system that cry out for reform.  Every physician can offer their own similar vignettes.  It’s hard to be sick and the road to recovery may be difficult.  Should these patients also have to carry the burden that their treatments and cures won’t be covered?  I’m not referring to coverage for experimental or ‘promising’ treatments which are more controversial.  I am referring to established medical treatments.

Throughout my entire career, I have watched the tension between medicine, the profession, and medicine the business.  Guess which side I’m on.