The state of Washington is adding a public option to its health insurance marketplace; Massachusetts, Connecticut, and others have passed laws requiring that payers cover fertility preservation procedures for patients with cancer. Many states are seeking to expand Medicaid eligibility, and some, in a controversial step, are moving to tie eligibility to work requirements.
Robert W. Carlson, MD
Terrell Johnson, MPA
In fact, states are playing “a huge and growing role” in health-care policy, said Connecticut state senator Matthew Lesser, who was the keynote speaker at the recent National Comprehensive Cancer Network® (NCCN®) Policy Summit, which examined the impact of state policies on access to high-quality cancer care.
Senator Lesser, a young cancer survivor who is the state senate’s Deputy Majority Leader, Chair of the Insurance and Real Estate Committee, and Vice Chair of the Public Health Committee, described legislative efforts that have succeeded in Connecticut (eg, coverage for fertility preservation) and one bill that did not pass (adding a public option to the state’s health insurance exchange). But it’s not just Connecticut. Around the country, he said, “states are driving the agenda.”
The NCCN Policy Summit brought together representatives from clinical, pharmaceutical, insurance, and patient advocacy groups to explore issues that have come with the shifts in federal and state power. The meeting’s goals, said NCCN’s Chief Executive Officer, Robert W. Carlson, MD, were twofold: to explore innovative concepts for improving health-care delivery at the state level and to highlight areas of concern regarding inequities in access to high-quality care.
Organized by Terrell Johnson, MPA, an NCCN Policy and Advocacy Fellow, the meeting included two panel discussions moderated by Clifford Goodman, PhD, Senior Vice President of The Lewin Group. The first panel discussed the regulatory tools that states are using to try out innovative ideas. The second focused on current policy trends at the state level and their potential implications for patients with cancer.
The Affordable Care Act (ACA) of 2010 laid the basic groundwork for the states’ growing policy role. It gave them the flexibility to request waivers for certain provisions of the law and to experiment with other methods of providing equivalent coverage. Known as Section 1332 waivers or State Innovation Waivers, they allow states to modify programs regarding benefits, subsidies, insurance exchanges, and individual and employer mandates. Health insurance offered through the modified state programs must be as accessible, comprehensive, and affordable as before the waiver and cannot add to the federal deficit. Section 1332 does not allow waivers of the ACA’s protections for people with preexisting conditions, its prohibitions on health status and gender rating, or its nondiscrimination rules.
Clifford Goodman, PhD
Anne Levine, MEd, MBA
Some of the most dramatic efforts at the state level have been those to add a public option to online health insurance marketplaces. Connecticut’s proposed bill met strong opposition from insurance companies in the state and was defeated, but Washington’s bill was signed into law in May 2019. Colorado and New Mexico have passed bills to create or study a public option.
Two other state health insurance plans predate the ACA: The Massachusetts’ plan, passed in 2007, served as the model for the 2010 federal law. Today, 97% of the state’s residents have health coverage, said panelist Anne Levine, MEd, MBA, Vice President for External Affairs at the Dana-Farber Cancer Institute. And Indiana has its own public plan for lower-income residents who are not eligible for either Medicare or Medicaid. Launched in 2008, the Healthy Indiana Plan has provided coverage to more than 400,000 Hoosiers, including many patients with cancer, said panelist John R. Edwards, MD, Co-Medical Director of Indiana Blood and Marrow Transplantation.
States are also using legislation to address specific issues. Massachusetts, for instance, is considering a bill like Connecticut’s to require coverage of fertility preservation for women with cancer, and another bill on oral chemotherapy parity was passed in 2013. Ms. Levine said in a statement that a third proposal would ban the insurance practice of “fail first.” Also known as step therapy, this rule blocks patients’ access to more advanced treatments until they have tried, and had a poor outcome on, older, lower-cost therapy.
Another source of innovation is Section 1115 of the Social Security Act, which allows states to apply for waivers to test new approaches to Medicaid. Many states have used the tool to expand Medicaid eligibility to more residents, including those with incomes of up to 138% of the federal poverty level. Doing so makes a state eligible for federal matching funds to cover 90% of the cost of expansion. Some states are now working to implement “partial expansions,” limiting enrollment more stringently to those below the federal poverty level.
Areas of Concern
The proposals for partial Medicaid expansions have raised concerns that they could cover fewer people at a higher federal cost. However, this is not the only area in which new state policies may be limiting, rather than increasing, access to health care.
Some experts note that proposed work requirements for Medicaid patients are troubling. Starting in 2018, states have been allowed to use Section 1115 to request approval for requirements that Medicaid recipients work or engage in other activities, such as schooling, caregiving, or community volunteer projects.
Work requirements have been approved by the Center for Medicare and Medicaid Services in nine states, as of mid-2019, according to a Commonwealth Fund Issue Brief, although some are facing legal challenges. Courts in at least two states, Kentucky and Arkansas, had blocked their implementation as of June 2019.
Another area of concern that affects patients with cancer in particular are insurance plans based on “narrow networks” of providers, which usually do not include physicians at academic cancer centers. An NCCN survey, conducted by Avalere Health from December 2017 through January 2018, found that of 29 responding cancer centers, 25 were in network for some, but not all, ACA exchange plans available in their state. Two more centers were excluded from all their states’ exchanges. The percentage of centers that were excluded despite attempting to be in network rose slightly from 2017 to 2018.
Plans with narrow networks may technically meet the ACA’s requirement that they cover “adequate care.” However, that general term can be interpreted broadly. “The availability of an oncologist is not enough,” Dr. Carlson said in an interview. “Patients should have access to an oncologist who is experienced in his or her particular type of cancer.”
Keysha Brooks-Coley, MA
Another major concern are short-term and association health plans, not originally allowed on the ACA -marketplaces but now permitted. “These plans are not adequate,” stated panelist Keysha Brooks-Coley, MA, Vice President for Federal Advocacy and Strategic Alliances in the American Cancer Society’s Cancer Action Network. The low-premium plans are not only exempt from ACA requirements—for example, coverage can be denied for preexisting conditions—but they can also exclude coverage and leave patients in situations where they have to pay out of pocket for care that can be expensive, she said. Co-pays are much higher, and overall coverage is not as extensive.
In one positive development, nine states and the District of Columbia have either passed laws or introduced legislation to limit the sale of short-term plans and bolster consumer protections, according to an issue brief from the Commonwealth Fund. But like other modifications to the ACA, the status of short-term plans differs from state to state. In fact, variations in policy among the states are, in themselves, concerning to many oncologists and policy makers.
DISCLOSURE: Dr. Carlson, Ms. Brooks-Coley, Dr. Goodman, Mr. Johnson, Senator Lesser, Dr. Edwards, and Ms. Levine reported no conflicts of interest.