Federal officials will allow some flexibility in meeting new requirements on covering the costs of clinical trials for people enrolled in Medicaid, seeking to accommodate states where legislatures will not meet in time to make needed changes in rules.
Congress in 2020 ordered 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.
The mandate went into effect on January 1, but the Centers for Medicare & Medicaid Services (CMS) will allow accommodations in terms of implementation time for states that have not yet been able to make needed legislative changes, wrote Dan Tsai, the director of Medicaid, in a December 7 letter. Tsai's letter doesn't mention specific states. CMS didn't immediately respond to a request seeking information on the states expected to apply for waivers.
Medicaid has in recent years been a rare large US insurance program that does not cover the costs of clinical trials. The Affordable Care Act of 2010 mandated this coverage for people in private insurance plans. The federal government in 2000 decided that Medicare would do so.
"A Hidden Opportunity"
A perspective article last May in the New England Journal of Medicine referred to the new Medicaid mandate on clinical trials as a "hidden opportunity," referring to its genesis as an add-on in a massive federal spending package enacted in December 2020.
In the article, Samuel Takvorian, MD, MSHP, of the University of Pennsylvania, Philadelphia, and co-authors noted that rates of participation in clinical trials remain low for racial and ethnic minority groups, due in part to the lack of Medicaid coverage.
"For example, non-Hispanic White patients are nearly twice as likely as Black patients and three times as likely as Hispanic patients to enroll in cancer clinical trials — a gap that has widened over time," Takvorian and co-authors write. "Inequities in enrollment have also manifested during the COVID-19 pandemic, which has disproportionately affected non-White patients, without their commensurate representation in trials of COVID-19 therapeutics."
In October, researchers from the Arthur G. James Cancer Hospital and Ohio State University, Columbus, published results of a retrospective study of patients with stage I-IV pancreatic cancer that also found inequities in enrollment. Writing in the Annals of Surgical Oncology, Mariam F. Eskander, MD, MPH, and co-authors reported what they found by examining records for 1127 patients (0.4%) enrolled in clinical trials and 301,340 (99.6%) who did not enroll. They found that enrollment in trials increased over the study period, but not for Black patients or patients on Medicaid.
Eskander told Medscape Medical News the new Medicaid policy will remove a major obstacle to participation in clinical trials. An oncologist, Eskander said she is looking forward to being able to help more of her patients get access to experimental medicines and treatments.
But that may not be enough to draw more people with low incomes into these studies, said Eskander, who is now at Rutgers University. She urges greater use of patient navigators to help people on Medicaid understand the resources available to them, as well as broad use of Medicaid's nonemergency medical transportation (NEMT) benefit.
"Some patients will be offered clinical trial enrollment and some will accept, but I really worry about the challenges low-income people face with things like transportation and getting time off work," she said.
