Congress has ordered the holdouts among US states to have their Medicaid programs cover expenses related to participation in certain clinical trials, a move that was hailed by the American Society of Clinical Oncology (ASCO) and other groups as a boost to trials as well as to patients with serious illness who have lower income.
A massive wrap-up spending/COVID relief bill that was signed into law December 27 carried with it a mandate on Medicaid. States are ordered to put in place Medicaid payment policies for routine items and services, such as the cost of physician visits or laboratory tests, that are provided in connection with participation in clinical trials for serious and life-threatening conditions. The law includes a January 2022 target date for this coverage through Medicaid.
Medicare and other large insurers already pick up the tab for these kinds of expenses, leaving Medicaid as an outlier, said ASCO in a press statement. ASCO and other cancer groups have for years pressed Medicaid to cover routine expenses for people participating in clinical trials. Already, 15 states, including California, require their Medicaid programs to cover these expenses, according to ASCO.
"We believe that the trials can bring extra benefits to patients," said Monica M. Bertagnolli, MD, of Dana-Farber Cancer Institute, Boston, Massachusetts. Bertagnolli has worked for years to secure Medicaid coverage for expenses connected to clinical trials.
Although Medicaid covers costs of standard care for cancer patients, people enrolled in the program may have concerns about participating in clinical studies, said Bertagnolli, who is the chair of the Association for Clinical Oncology, which was established by ASCO to promote wider access to cancer care. Having extra medical expenses may be more than these patients can tolerate.
"Many of them just say, 'I can't take that financial risk, so I'll just stay with standard of care,' " Bertagnolli told Medscape Medical News.
Equity Issues
Medicaid has expanded greatly, owing to financial aid provided to states through the Affordable Care Act (ACA) of 2010.
To date, 38 of 50 US states have accepted federal aid to lift income limits for Medicaid eligibility, according to a tally kept by the nonprofit Kaiser Family Foundation. This Medicaid expansion has given more of the nation's working poor access to healthcare, including cancer treatment. Between 2013 and January 2020, enrollment in Medicaid in expansion states increased by about 12.4 million, according to the Medicaid and CHIP Payment and Access Commission.
Medicaid is the nation's dominant health insurer. Enrollment has been around 70 million in recent months.
That tops the 61 million enrolled in Medicare, the federal program for people aged 65 and older and those with disabilities. (There's some overlap between Medicare and Medicaid. About 12.8 million persons were dually eligible for these programs in 2018.) UnitedHealth, a giant private insurer, has about 43 million domestic customers.
Medicaid also serves many of the groups of people for which researchers have been seeking to increase participation in clinical trials. ASCO's Association for Clinical Oncology and dozens of its partners raised this point in a letter to congressional leaders on February 15, 2020.
"Lack of participation in clinical trials from the Medicaid population means these patients are being excluded from potentially life-saving trials and are not reflected in the outcome of the clinical research," the groups wrote. "Increased access to clinical trial participation for Medicaid enrollees helps ensure medical research results more accurately capture and reflect the populations of this country."
The ACA's Medicaid expansion is working to address some of the racial gaps in insurance coverage, according to a January 2020 report from the nonprofit Commonwealth Fund.
Black and Hispanic adults are almost twice as likely as White adults to have incomes that are less than 200% of the federal poverty level, according to the Commonwealth Fund report. The report also said that people in these groups reported significantly higher rates of cost-related problems in receiving care before the Medicaid expansion began in 2014.
The uninsured rate for Black adults dropped from 24.4% in 2013 to 14.4% in 2018; the rate for Hispanic adults fell from 40.2% to 24.9%, according to the Commonwealth Fund report.
There are concerns, though, about attempts by some governors to impose onerous restrictions on adults enrolled in Medicaid, Bertagnolli said. She was president of ASCO in 2018 when the group called on the Centers for Medicare & Medicaid Services to reject state requests to create restrictions that could hinder people's access to cancer screening or care.
The Trump administration encouraged governors to adopt work requirements. As a result, a dozen states approved these policies, according to a November report from the nonprofit Center on Budget and Policy Priorities (CBPP). The efforts were blocked by courts.
Data from the limited period of implementation in Arkansas, Michigan, and New Hampshire provide evidence that these kinds of requirements don't work as intended, according to the CBPP report.
"In all three states, evidence suggests that people who were working and people with serious health needs who should have been eligible for exemptions lost coverage or were at risk of losing coverage due to red tape," wrote CBPP analysts Jennifer Wagner and Jessica Schubel in their report.
In 2019, The New England Journal of Medicine (NEJM) published an article about the early stages of the Arkansas experiment with Medicaid work rules. Almost 17,000 adults lost their healthcare coverage in the initial months of implementation, but there appeared to be no significant difference in employment, Benjamin Sommers, MD, PhD, of the Harvard School of Public Health, Boston, Massachusetts, and colleagues wrote in their article.
For many people in Arkansas, coverage was lost because of difficulties in reporting compliance with the Medicaid work rule, not because of the employment mandate itself, according to the authors. More than 95% of persons who were targeted by Arkansas' Medicaid work policy already met its requirements or should have been exempt, they wrote.
Democrats have tended to oppose efforts to attach work requirements, which can include volunteer activities or career training, to Medicaid. Bertagnolli said there is a need to guard against any future bid to add work requirements to the program.
Extra bureaucratic hurdles may pose an especially tough burden on working adults enrolled in Medicaid, she said.
People who qualify for the program may already be worried about their finances while juggling continued demands of child care and employment, she said. They don't need to be put at risk of losing access to medical care over administrative rules while undergoing cancer treatment, she said.
"We have to take care of people who are sick. That's just the way it is," Bertagnolli said.
