By Dr. Le Ondra Clark Harvey
Across California and the nation, too many patients are blocked from timely, medically appropriate care by a practice known as step therapy. Often called “fail first,” step therapy is too often used as a blunt instrument – one that ignores individual history, medical complexity, and clinical risk.
Under these policies, insurers force patients to try one or more cheaper, insurer-preferred treatments before covering what the patient’s clinician originally prescribed. Insurers claim it is a cost-saving measure that prevents patient harm, but real-world experiences and data paint a far different picture – one of delayed care, worse outcomes, and eroded trust in the health care system.
As a breast cancer survivor, I dealt with these policies first-hand. When you hear the words “you have cancer,” the last thing you should have to worry about is whether your insurer will allow the treatment your doctor knows you need. Yet too often, we as patients are forced into a complex maze of step therapy protocols, prior authorizations, and appeals. At the very moment when clarity and speed matters most, we lose precious time navigating a system that feels like it’s designed to benefit insurers, not patients.
Beyond physical health, the behavioral health impacts of managing a debilitating illness – while fighting every step of the way – are significant and too often ignored.
My time spent as a psychologist and policy advocate for those with behavioral health conditions means I’ve watched countless individuals struggle not only with illness, but with a system that makes them “prove” they’re sick enough before receiving care. Delays in treatment for this population aren’t just inconvenient, they are blatantly dangerous.
In Los Angeles, where more than 72,000 people experience homelessness on any given night, untreated mental illness and substance use disorders are among the most common underlying factors. I regularly hear from providers in South LA, Skid Row, the San Fernando Valley, and East LA who describe clients losing stability because they were abruptly forced to switch medications, despite no clinical need to do so, or wait weeks for approval while symptoms spiraled. In practice, this means someone with major depression is being forced to go on medications that they tried years ago with no success; someone with schizophrenia being destabilized because they were taken off a medication that was keeping them well; or someone in recovery relapses while waiting for insurance to approve the treatment their provider recommended in the first place.
The consequences of delayed or denied behavioral health care extend far beyond the clinic; in fact, the consequences regularly spill into our streets. When people with serious mental illness or substance use disorders are forced to “fail first,” treatment interruptions can trigger relapse, worsening psychiatric symptoms, or crisis, often leading to job loss, housing instability, and ultimately homelessness.
The homelessness crisis in Los Angeles cannot be separated from our current health care system. We know stability can be fragile and trust is essential, but our current system allows insurers to mandate ineffective treatments – it’s not just inefficient, it’s harmful and can be the tipping point that pushes people into homelessness.
Step therapy is not clinical care. It’s administrative control masquerading as medicine.
It must stop, and Los Angeles’ own, Assemblymember Harabedian, agrees.
He introduced AB 1970 to reform portions of our health care system to require insurers to respect clinical judgement when there is documented medical need, honor prior treatment history when patients change health plans, respond to exception requests quickly, limit the number of forced “steps,” and create a transparent, accessible appeals process.
The bill is not about eliminating cost control. It’s about restoring balance so profit-margins do not override medical expertise, human dignity, or the urgency of care.
While California won’t be the first state to reform step therapy, we do have an opportunity to pass one of the most comprehensive pieces of legislation on this topic.
In 2024, Illinois passed a bill that banned step therapy and prior authorization for crisis mental health care. AB 1970 goes further. Whether the medication is related to behavioral health, oncology, neurology, or chronic disease, insurers will no longer be able to override clinical decisions.
As a survivor, an advocate, and a behavioral health policy leader, I believe deeply that our system must do better. When care is delayed, people suffer, and the system ultimately pays more in crisis care than it would have by providing timely, appropriate treatment in the first place.
Health policy should always be grounded in science, compassion, and common sense, not red tape that stands between patients and healing.
Step therapy reform is not a niche issue, it’s a patient access issue, a civil rights issue, and a public health issue. We owe it to every person facing illness, especially those living with mental health and substance use challenges, to make sure their care is guided by what’s medically right, not what’s administratively cheapest.
That’s how we build a health care system that truly puts people first.
Le Ondra Clark Harvey, PhD, is the CEO of the California Behavioral Health Association.