PROVIDENCE – The work of state legislators in the 2025 session of the R.I. General Assembly grinds on, despite the constant swells and upheavals in the economic market and turmoil and disruption in our national politics. Each week, there are hearings and testimony given in support of legislation seeking to change the way that the state does its business – hopefully for the better. Underneath all of the hearings and legislation is the common knowledge that the health care delivery system is in crisis.

Some issues – such as curbing payday lending or increasing the investment in the supply of affordable housing – are yearly struggles to change Rhode Island for the better. Then there is the reality that one-third of Rhode Island residents are dependent upon Medicaid for their health insurance – the biggest item in the state’s annual budget, but the low rates for providers represent the biggest impediment to future prosperity in Rhode Island.

Another major issue that emerges every year is whether or not Rhode Island will create a bottle bill. This year, four environmental groups have come together as a coalition to introduce legislation to create a modern version of the bottle bill. It remains an issue very much under the radar screen, it seems.

A step in the right direction.    
Another long-term issue on the legislative agenda is a proposal to rein in what is known as step therapy – a way that health insurers attempt to manage utilization issues around the high cost of retail pharmacy and drugs delivered by infusion.

Last week, Sen. Linda L. Ujifusa and Rep. Michelle McGaw introduced legislation [S0116 and H5119] to rein in so-called step therapy and protocols by health insurance companies that can delay or prevent patients from getting tests, procedures and drugs ordered by their physicians, according to the news release put out by the news bureau of the Rhode Island General Assembly.

Step therapy, also known as “fail first” therapy, is a health insurance practice that requires patients to try less expensive treatments before more costly ones are covered, according to the news release. Although insurers claim step therapy helps patients and manages costs, it can also delay, disrupt and even prevent patients’ access to medically necessary health care and restrict patients from getting the care their doctors ordered.

If the legislation were to be enacted, it would ensure that health insurers cannot use step therapy when the “steps” required are:

•    Contra-indicated by the patient’s other drugs or therapies.
•    Expected to cause an adverse reaction.
•    Have been tried and found ineffective or is expected to be ineffective
•    Would delay or prevent medically necessary care, or
•    Would disrupt the patient’s current effective drug regimen.

“These seem so common sense, it is hard to believe we must pass a law to prohibit insurers from requiring it, but unfortunately, we do,” said Sen. Ujifusa.

Rep. McGaw, who works as a licensed pharmacist, talked about the importance of the legislation in setting parameters: “The bill sets parameters around step therapy to be sure that our health care providers have greater agency in determining what is most appropriate for patients.”

“Step therapy cannot be allowed to be one more ‘utilization management’ tool used by insurers and pharmacy benefit managers to prioritize their financial interests over patient welfare,” Sen. Ujifusa argued.

Thirty-eight states have already enacted laws that explicitly limit step therapy, and federal legislation was introduced last year, although it has not advanced in Congress, according to the news release.

Because of its lack of legislation, Rhode Island has been given an “F” grade by the National Organization for Rare Disorders on its state report card on step therapy policies.

In addition, multiple patient advocacy groups, including the American Cancer Society, Cancer Action Network, the National Organization for Rare Disorders, the ALS Association, the Chronic Disease Coalition, the Rhode Island Medical Society and Newport Mental Health, as well as many local primary care providers, support the Rhode Island bill.

What the data shows    
The most recent data analysis conducted by the R.I. Office of the Health Insurer Commissioner, released in February of 2025 in OHIC’s 2024 annual report on “Health Care Spending and Quality in Rhode Island, found that “per capita spending in the commercial market was driven by growth in Retail Pharmacy and Hospital Outpatient spending,” with per capita spending on Retail Pharmacy having increased by 6.3 percent.

Retail Pharmacy was also identified as a cost driver in the Medicare Service Category, with spending on Retail Pharmacy increasing by 4.3 percent.

In the Medicaid Service Category cost driver analysis, Retail Pharmacy grew by 8.7 percent.

Further, in the analysis of spending on hospital outpatient services, drugs were identified as a major cost driver, including chemotherapy and other infusion drugs that are sometimes administered in an outpatient setting. In its “deep dive” analysis, the OHIC report found that “very expensive drugs were used more frequently, which contributed to the rising payments for this category.”

What the insurance companies say    
In numerous interviews conducted over the last few years by ConvergenceRI with Martha Wofford, president and CEO of Blue Cross and Blue Shield of Rhode Island, she has always pinpointed “pharmacy [as] the biggest driver of increased health care costs.”

In a 2021 interview, Wofford did not mince words about what she believes are the root causes behind increased health are costs. “Pharmacy now makes up a third of all health care costs,” Wofford. “And specialty pharmacy is now over 50 percent of that total pharmacy spend.”

Wofford continued: “When we say specialty pharmacy we are talking about a small number of very expensive drugs. These drugs have huge variations in cost from drug to drug, and quite incomplete quality information.”

In that interview, Wofford shared her alarm about the increasing pharmacy spend. “I was actually alarmed when the team shared this data point with me – that for Blue Cross [and Blue Shield of RI], 1 percent of our pharmacy claims equals 50 percent of our pharmacy spend.”

As ConvergenceRI wrote in the 2021 interview, Wofford had sounded a bit more like a consumer’s advocate and not the president and CEO of the state’s largest commercial health insurance firm: The culprit behind the rising pharmacy costs is Big Pharma, she argued.

 “I just saw a study about how Abbvie, the manufacturers of Humira, spent $1.5 billion on advertising for Humira over a three-year period,” Wofford said in the 2021 interview. “I think Humira is an example of big price increases – a 10 percent increase last year, with no change in the drug.”

That kind of dramatic price increase, Wofford continued, “is allowed to happen only because Big Pharma spends so much money on lobbying, more than any other industry,” expressing her exasperation at the outsized role that Big Pharma plays in lobbying Congress, enabling it to hike drug prices unfettered.

Fast forward to the summer of 2024, when ConvergenceRI published a two-part interview with Wofford, which included more discussion around the drivers of pharmacy costs, including the role played by pharmacy benefit managers.

ConvergenceRI: Yesterday I was reading the STAT newsletter, and they were claiming that it was the middle people who are profiting from pharmacy – the pharmacy benefit managers, [including] Optum [a wholly owned for-profit subsidiary of UnitedHealthcare], which it turns out is one of the largest pharmacy benefit managers.    
WOFFORD: I don’t think they are the largest. I think Express Scripts and CVS/Caremark are the two largest, And then, Optum is the third. I think they are the big three. But I think Optum is the smallest of the three.

ConvergenceRI: Small?    
WOFFORD: Of the big three? I think Optum is the smallest, but I would just say, if you ask the Pharma companies what their profit margin is, I think it is an interesting question. I think it is 70 percent.

Are there lots of flaws with the PBM business model? Yes. Like the big three and how their business practices [are run]. I think that there are a lot of challenges, and a lack of transparency.

We are part of Prime Therapeutics, which is a pharmacy benefits solution company that is transparent. So, I am a big believer in being able to see the flow of dollars, and I think that is something that the big three PBMs are not.

I think there are a lot of problems with them, but I would also say: look at the Pharma companies, look at what is happening at GLP-1’s [the anti-obesity drugs] right now, look at the pricing of those. [One is] a thousand dollars a month here and just $95 in France; it’s not about the cost of the drug. The profit margins that Phama is enjoying are incredibly high.

So, I don’t think we need to point at the PBMs and say, “They are the problem.” I would say that, for Rhode Islanders, the cost of prescriptions keeps going up. And, it’s not sustainable. And so, we have to figure out a way to bring those costs down.

And so, I think writing stories about the outrageous costs that people are experiencing is really helpful, because it is an ongoing challenge. We’ve had a 43 percent compound annual growth rate in costs of specialty drugs over the past five years. It’s just not sustainable for people.

And these are such expensive drugs. We are the cost-sharer for these drug. And they are really, really high. And, we have to figure out a way to address it. We’re doing a lot of things we are excited about, and we are proud of, and it’s really, really hard to make progress.

And, I look at the Pharma companies, and I think about how we get beat all the time on the lobbying sector. And the fact that you think now that it is the middleman and the PBM…

Hiding in plain sight?    
One of the other big drivers in the high cost of specialty drugs is the growth in chronic diseases related to immunological disorders, such as multiple sclerosis. In 2019, a report published by the Blue Cross Blue Shield Association found that Rhode Island had the second highest multiple sclerosis diagnosis rate in the United States – 36 diagnosed per 10,000 people.

[Editor’s Note: Multiple Sclerosis is a life-long disease of the central nervous system that disrupts the body’s ability to send neurological signals within and between the brain and other parts of the body, often leading to progressive physical and cognitive decline, according to Dr. Matt Collins, the former chief medical officer at Blue Cross and Blue Shield of Rhode Island. The cause of MS is not known and there is no cure yet.]

The report, which looked at commercially insured members of Blue Cross and Blue Shield companies from 2014 to 2017, also found that 75 percent of those diagnosed with MS were women and that the average age of someone living with MS was 47 years old.

Translated, the high number of Rhode Islanders who have been diagnosed with multiple sclerosis, which is often treated with infusion treatments of expensive drugs, could be seen as a source of higher drug costs.

Earth Day, April 22, is a week away    
Like efforts to rein in “step therapy,” efforts to enact a bottle bill in Rhode Island have a long legislative history. This year, new legislation has been introduced based upon the work of a study commission.

Four leading environmental groups – Save The Bay, Clean Water Action, the Audubon Society of Rhode Island and Just Zero – praised the introduction of two new bills that would fight waste and litter by establishing a Rhode Island “bottle bill.”

The legislation – House 6206 [sponsored by Rep. Tina Spears] would create a bottle deposit return system for Rhode Island and House 6207 [sponsored by Rep. Carol Hagan McEntee] would create a bottle return system as well as an extended producer responsibility program..

“Over the last 18 months, our organizations have participated in a bipartisan study commission alongside elected officials and other stakeholders,” the four groups said in a joint statement. “The study commission brought in experts from across the country, examined our state’s recycling and waste systems, and listened to local business owners.”

The joint statement continued:  “We studied recycling systems in states with bottle bills and worked to develop a plan for Rhode Island. It is now clearer than ever that bottle bills both reduce litter and improve recycling, and the bills introduced today are the result of this careful, deliberative process.”

A 20-member Special Joint Legislative Commission to Study and Provide Recommendations to Protect our Environment and Natural Resources from Plastic Bottle Waste met 13 times over the past 18 months.

The Final Report of the Commission recommends that the General Assembly adopt a deposit return system for beverage containers, as well as a broader producer responsibility system for other forms of packaging. Ten U.S. states – including neighboring states of Massachusetts, Connecticut, New York, Vermont and Maine – have had ‘bottle bill’ systems for decades.

“I've introduced a bottle bill for several years, and this is the best version yet," said Rep. Carol Hagan McEntee, Commission Co-Chair and sponsor of H6207, in the news release. “We listened closely to all of the interested parties and worked hard to write a bill that takes their concerns into consideration and creates something that will both reduce litter and improve recycling, with zero cost to taxpayers.” Under the proposed legislation, all costs for operating the bottle deposit and packaging systems would be borne by a nonprofit producer responsibility organization.

‘This is not your grandfather’s bottle bill,” said Sen. Mark McKenney, who co-chaired the study commission. “In studying the problem diligently, the Commission learned of the latest and best practices - around our nation and the world. People are angry about pollution, and angry about how little of their present recycling actually results in a new product. We have solutions. It’s time to get this done.”

"Beverage containers are among the most collected items during shoreline cleanups, and microplastic pollution is a growing problem in Narragansett Bay,” said Jed Thorp, Director of Advocacy at Save The Bay. “While there are many things we can do to improve recycling, a bottle bill is the only proven policy to get beverage container pollution out of the environment.”

“Bottle bills are not only the right policy choice – they are extremely popular. A poll in Rhode Island this winter showed support for a bottle bill by a 27 perent margin. Over the last three years, Clean Water Action organizers have knocked on doors and called and emailed residents, and people get it. We have a litter problem and a landfill space problem, and a bottle bill addresses both,” said Emily Howe, Clean Water Action’s Rhode Island director.