story time: one of my daily medications is called verapamil. like a lot of medications, it can be prescribed for multiple purposes and at multiple doses. i've been taking it for several years as 100 mg capsules (1/day) for migraine prevention. it's always been on the expensive side, but in 2022 i switched to a different insurance provider and the cost skyrocketed to being over $100/month. i brought it up with my doctor during my annual physical last month and she was like "that's fucking ridiculous" and grabs her laptop and clicks around a bit. turns out that my insurance company just... doesn't cover that dosage of verapamil for migraine prevention. they will cover 120 mg tablets 1/day for that use, though, so when i run out of my current supply of the 100 mg capsules my doctor will send a new prescription for the tablets because she doesn't think the extra 20 mg per day will hurt me and it's worth going from "not covered and thus super expensive" to (we think) "totally covered, lowest copay."
the thing is, the insurance company didn't give the pharmacy any information about why the cost for the original dosage was so high (more than one member of the staff appeared confused by it, in fact, as verapamil is not a new or uncommon medication) and neither did they even bother to attempt to contact my doctor about it. the only reason i am going to be able to switch to a more affordable option is because my pharmacy is staffed by people who care enough to say "hey there's something not right about this pricing, you should talk to your doctor about it" and my doctor is a goddamn superhero who i can come to with a list of issues/questions and know that she will go through each and every one with me and give each one the full attention it deserves. (there's a reason why i still go to her even though when i started grad school i moved three hours away from where she's located, lol.)
meanwhile, i take several medications to help manage a number of chronic issues (migraines, chronic non-migraine headaches, depression, anxiety), so part of the calculus here is thinking about how changing the dosage of the verapamil might affect the other meds in addition to how it might affect me. luckily in this case it's a small enough change (for this medication) that it didn't worry my doctor to make that call. now, knowing my doctor, i know that if she had felt she couldn't change the dosage or change the medication, she would have gone to bat for me with the insurance company, but there's no guarantee she would have been successful in getting them to make an exception. they wouldn't have taken into account anything else about me, just their rules about when and how they are willing to accept a doctor prescribing a medication for a slightly off-label but generally accepted reason (verapamil is officially a blood pressure medication but even just a cursory regular google search indicates to me that there is a decent amount of research showing it can be an effective preventative treatment for migraine/cluster headaches).
because here's the thing: american insurance companies don't care about the quality of care that their customers receive. they only care about the profits of the insurance company. so they make decisions about what medications can be prescribed for what conditions and be covered based on statistical analyses of the profitability or lack thereof of doing so, plus what they can get away with. that's why when drug manufacturers decide to raise the cost of their drugs, health insurance companies will just shrug and pass the cost on to consumers.
another example: my dad was in the military for 30 years and only just turned 65 this past year, therefore aging out of the military retiree healthcare system and onto medicare (mostly, idk, his prescriptions are still free through the military system). so now for the first time in decades my parents are seeing benefit statements whenever they receive care that explicitly lay out (1) what the provider charged for a given service, (2) what medicare actually paid, and (3) the cost that no one pays because they don't have to and medicare won't. my dad had to get outpatient eye surgery for cataracts in both his eyes, which involved a set of multiple appointments over the course of months during which first one eye and then the other was treated, plus after that he had to get a totally new glasses prescription. every time he gets a statement of benefits that covers some aspect of that process, the difference between what the provider charges and what medicare covers (aka what medicare deems the fair cost) is thousands of dollars. which he doesn't have to pay for whatever reason (i think but would definitely not swear to it that the provider just has to write it off because medicare but someone who knows how insurance works can correct me in the inevitable case that i'm wrong). but the average person on average insurance? would be responsible for covering the difference, which again is between what the government has deemed a fair cost and what the provider is charging above that fair cost. which is, uh, profoundly unfair.
medicare is not even close to a perfect system. if the US does move to a nationalized health service, medicare for all is, like, the first step. but it would give us something to build on, something that isn't first and foremost a capitalist profit venture that incidentally involves people's healthcare.