This op-ed originally appeared in The Hill on February 4, 2019.
When then-President Lyndon Johnson signed Medicare into law in the summer of 1965, he declared, “No longer will older Americans be denied the healing miracle of modern medicine.”Johnson’s pledge was as prophetic as it was audacious: Medicare fundamentally transformed health care, giving seniors unprecedented access to the medicine and services they need to live longer, healthier lives.That promise now hangs in the balance. The Trump administration is pushing policies that threaten to undermine Medicare coverage for many of America’s most vulnerable seniors and people with disabilities. The worst of these misguided proposals could kill people. This might sound hyperbolic, but it’s not.
The Trump administration is seeking to put these policies in place through a Centers for Medicare and Medicaid Services (CMS) proposed rulereleased in November that, if finalized, will unravel long-standing coverage protections for six categories of illness, including cancer, HIV/AIDS and mental health.
Until now, the Part D plans that provide Medicare prescription drug coverage were required to cover most medications within those so-called “six protected classes” because the treatments are highly specialized. The safeguards exist to ensure patients’ access to necessary medicine.
This policy shift could restrict the options available to patients and prevent doctors from prescribing individualized treatments for some of the most vulnerable patients. This is particularly troubling for patients whose existing regime will be disrupted by the change, forcing them to abandon effective treatments for less-effective options that Part D plans may prefer.
In some cases, this change could block patients’ access to the only effective therapy to treat their specific illness. The American Cancer Society’s Cancer Action Network warned that excluding treatments for certain conditions “would be tantamount to backdoor discrimination.” The group pointed out that many new cancer therapies are designed to treat a very specific condition, and there is often no therapeutic equivalent.
CMS did not stop there. Under this new proposal, patients who are finally stable on a medicine in the six protected classes would find themselves at risk for no longer having coverage for that medicine. This is because CMS will let insurance companies second guess doctors by forcing stable patients to prove they meet the health plan’s criteria for coverage of a drug. Health plans will also be allowed to force patients to fail first on one treatment before the plan lets them resume taking a medicine that has already been shown to work for them.
These changes could be a disaster for patients with chronic illnesses who have worked with their doctors to devise the best possible treatment plan, including cancer and HIV/AIDS patients whose long-term health will suffer if they are subjected to this multi-step process. For HIV/AIDS, the changes also have troubling implications for public health if patients are switched to older medicines that must be taken multiple times a day instead of once-a-day treatments that are easier for patients to take faithfully. There are myriad reasons for patients to stop taking the medicines prescribed for them, and this change could impose bureaucratic hurdles that give patients another big reason to abandon their treatment regimens.
CMS believes the shift will save money, but it could wind up costing the government much more by forcing patients into less-effective treatment plans before Medicare plans will cover the most effective medicine. And those disruptions can have catastrophic consequences if patients are forced off of their existing treatments just to prove other treatments are less effective.
Hundreds of prominent patient-advocacy groups have raised alarmsabout these proposals. “What is the point of having protected therapeutic classes, if they are not truly protected?” the head of the Community Oncology Alliance asked in a statement after the proposal was released.
Many of these groups warned that the proposal would reduce access to medicine patients need and questioned whether the proposal would even save money, especially if it results in increased hospitalizations because seniors will lose access to medicine on which they depend.
Medicare began with a promise — to give seniors access to the medical care they need. Part D expanded on that promise by making medicine more affordable. Since its inception, the program has been a huge success, expanding access to life-changing medication while staying well under budget.
This proposed rule fundamentally undercuts that promise by erecting barriers that interfere with successful treatment for the most at-risk patients.
If the Trump administration really wants to help patients, it should start by scrapping policy proposals could deny seniors “the healing miracle of modern medicine.”