• Medicaid programs can’t withhold a Hep C cure.

    It was only a matter of time. Last Friday, a federal judge in Washington State entered a preliminary injunction ordering the state’s Medicaid program to pay for direct-acting antivirals—think Harvoni or Sovaldi—for any beneficiary diagnosed with Hepatitis C.

    Like many states, Washington has a policy of refusing to supply the drugs until the disease has progressed far enough to seriously scar the patient’s liver. The reason is money: state Medicaid programs all over the country are buckling under the cost of paying for the new Hep C drugs. Limiting their availability is a rough-and-ready way to spread the costs of the new drugs over a number of years.

    But it’s not good medical care. Prominent clinical guidelines say that the new direct-acting antivirals should be offered to anyone with Hep C—no matter what their stage of disease. Why should your liver have to start turning into a raisin before you’re cured?

    In a clash between financial and medical necessity, the Medicaid statute sides with medical necessity. Under §1927(d), a state Medicaid program can decline to cover a drug if “the prescribed use is not for a medically accepted indication” or if the drug doesn’t have a “clinically meaningful therapeutic advantage” over alternatives. You can’t withhold cures just because they’re expensive.

    CMS apparently thinks so too. Back in November of last year, the agency published a letter expressing its “concer[n] that some states are restricting access to [direct-acting antivirals] drugs contrary to the statutory requirements in section 1927 of the Act by imposing conditions for coverage that may unreasonably restrict access to these drugs.”

    For the Washington judge, then, this was an easy case. Although the state argued that monitoring was medically appropriate for people with early-stage Hep C, it didn’t “address the liver damage that enrollees could suffer during this ‘monitoring’ period.” The state also claimed that limiting availability of the Hep C drugs might avoid “the currently ill-defined risks of these new medications.” The judge was scornful: “This assertion of ‘ill-defined risks’ is not supported by any clinical evidence and is contradicted by the [state’s] own documents.”

    A similar lawsuit has already been brought against Indiana’s Medicaid program, and I expect the outcome to be the same. The legal question here is not remotely difficult: under federal law, Medicaid beneficiaries diagnosed with Hepatitis C are entitled to a cure. The states may be under fiscal pressure, but that doesn’t make the drugs any less medically necessary. (Other cases have been brought against state prison systems for withholding the drugs, including in Pennsylvania. Those cases present somewhat different legal questions.)

    That’s not to slight Washington’s concerns with the extraordinary one-time costs of the new therapies. As Austin has written recently, innovation is likely to yield breakthrough drugs that puts even greater pressure on state budgets: “The day that [a] life-extending $1 million ‘miracle’ pill arrives (or the precision-medicine equivalent of a collection of drugs), we may look back on the current hepatitis C treatment funding problems nostalgically.”

    Before that day arrives, we need to think hard about how to afford state Medicaid programs more flexibility to spread the one-time costs of a breakthrough drug over a number of years. More generally, we’ll need to have a difficult conversation about how much we’re willing to spend on new therapies given other, competing priorities.

    In the meantime, though, I expect that the states will keep losing these Hep C lawsuits.

    @nicholas_bagley

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  • Should we help poor, sick people in Indiana get to the doctor? Discuss.

    I rewrote the title to this post eight times before I gave up. I’m too tired, frustrated, and annoyed with this week and this issue. Nonetheless, let’s dive in.

    As part of Medicaid, beneficiaries are eligible for a non-emergency medical transportation (NEMT) benefit. They get a ride to the doctor. They get this because people generally understand that if we don’t poor provide people, especially sick people, a way to get to the doctor, they can’t go.

    But in 2007, as part of their negotiation for the Healthy Indiana Plan (HIP), Indiana got a waiver for this benefit. The waiver was approved again in 2013, 2014, and 2015. As part of their negotiation to accept the Medicaid expansion in 2015, they got a waiver for HIP 2.0 for all beneficiaries except pregnant women, the medically frail, and certain smaller categories.

    But this waiver depended on them studying a “demonstration year”. They had to conduct an independent evaluation of the NEMT to see that the impact was. They hired the Lewin Group, and that report has now been published. The conclusion:

    In sum, the member survey shows a relatively small number of HIP 2.0 members missed appointments due to transportation-related issues. Also, members without NEMT benefits did not appear to be substantially more likely to report transportation problems relative to those with [managed care entitiy] MCE-provided or state-provided NEMT benefits. However, due largely to the limitations of the analysis, particularly the lack of comparable comparison groups, the picture is less clear regarding the extent to which the provision of NEMT coverage affects this issue. Future research could explore the use of a control group. In particular, if the NEMT benefits are similarly operationalized by the MCE and the state, it may be possible to conduct more robust comparisons of members within the population of members without state-provided NEMT based on whether their MCE provided NEMT or not.

    In other words, it seems fine not to cover transportation. This is the state-sponsored report, though. Others, including Marsha Simon, beg to differ:

    The evaluation found a significant number of individuals on Medicaid are missing appointments because they lack transportation.  According to survey results, 6 percent of Medicaid recipients under the waiver missed an appointment because they lacked the transportation benefit states are required to provide to Medicaid beneficiaries throughout the country. Even though this accounts for a relatively small proportion of enrollees, this figure nonetheless suggests there is unmet need for transportation to care among a portion of enrollees in the Healthy Indiana Program. Addressing this unmet need is the very rational[e] of the federal NEMT policy, a feature of the Medicaid program for the poor since it’s beginning in 1965. An entitlement to medical services is meaningless with no way to access the services.

    Further, the question of whether an appointment was missed is too narrow a measure of access to care, as it fails to identify Medicaid enrollees that do not schedule an appointment because they know they cannot get to the doctor’s office. With this in mind, those evaluating Iowa’s NEMT waiver asked beneficiaries whether they had an “unmet need for transportation to or from a health care visit.”  There, researchers found that 15 percent of those with incomes under 100% of poverty had an unmet need for transportation.

    One of the state’s managed care plans, Anthem, is continuing to provide this benefit even though the state refuses to reimburse the cost. I imagine they recognize that this probably improves outcomes. Maybe they even see that it is cost-saving because people who can get to the doctor in a cab might be less likely to call an ambulance (MUCH MORE EXPENSIVE) to go the emergency room (MUCH MORE EXPENSIVE) later. Other states agree:

    When considering a similar waiver, Arkansas hired The Stephen Group (TSG) to offer a recommendation on waiving NEMT benefits.  Their recommendation warned against dropping the benefit. Far from being an additional expense, TSG argued that NEMT benefits were a good investment for the state, citing a Florida State University study showing a return on investment factor of 11:1 for as well as a Transportation Research Board study finding a 10:1 return on investment. Providing Medicaid enrollees with transportation benefits allows them to access preventative care that forestalls more costly interventions down the road. After this recommendation, Arkansas quickly dropped their proposal to waive NEMT.

    Indiana’s waiver is set to expire in November. It’s up to the Obama administration whether to allow it to continue. We’ll see, I guess.

    @aaronecarroll

    P.S. As this focuses on Indiana, I feel the need to direct you to my always-true-disclaimer: The views in Aaron’s posts represent his views only.  They do not represent the views of Indiana University, any funding agencies or foundations,  any organizations, or especially any of his friends or family.

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  • Healthcare Triage News: Lots of People Are Still Uninsured

    Although the ACA has significantly reduced the percent of Americans who are uninsured, we have not yet come close to universal coverage. This has become a topic of focused debate among Democratic primary candidates. Short of achieving full coverage by passing a single-payer plan (which seems very unlikely in the near future), further gains in insurance coverage will come through means available through the ACA.

    It’s worth revisiting, therefore, exactly who constitute the uninsured at this point. A better understanding could allow policymakers and advocates to focus their efforts on those populations. A recent report from the Robert Wood Johnson Foundation and The Urban Institute covered just that. So do we, in this episode of Healthcare Triage News.

    This is based on Friday’s post over at AcademyHealth. Go read that, too!

    @aaronecarroll

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  • AcademyHealth: Who are the remaining uninsured?

    Although the ACA has significantly reduced the percent of Americans who are uninsured, we have not yet come close to universal coverage. This has become a topic of focused debate among Democratic primary candidates. Short of achieving full coverage by passing a single-payer plan (which seems very unlikely in the near future), further gains in insurance coverage will come through means available through the ACA.

    It’s worth revisiting, therefore, exactly who constitute the uninsured at this point. A better understanding could allow policymakers and advocates to focus their efforts on those populations. A recent report from the Robert Wood Johnson Foundation and The Urban Institute covered just that.

    So do I, over at the AcademyHealth blog in my latest post. Go read it!

    @aaronecarroll

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  • Healthcare Triage News: Premiums for CHIP and Medicaid Lead to Lower Enrollment and Uninsured Kids

    I have written before about the use of premiums in Medicaid programs across the United States. But a new study in Pediatrics collects the evidence, and it’s worth a look. “Medicaid and CHIP Premiums and Access to Care: A Systematic Review“. This is Healthcare Triage News.

    For those of you who want to read more:

    @aaronecarroll

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  • AcademyHealth: Premium increases and access to care: a systematic review

    I have written before about the use of premiums in Medicaid programs across the United States. But a new study in Pediatrics collects the evidence, and it’s worth a look. “Medicaid and CHIP Premiums and Access to Care: A Systematic Review”.

    Go read my latest post over at the AcademyHealth blog!

    @aaronecarroll

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  • AcademyHealth: The Affordable Care Act and Coverage of Childbirth

    One common argument from opponents of the Affordable Care Act is that an expansion of government into health care will result in “crowd out”, where private influences and coverage go down as public ones go up.

    But that’s not always the case, as seen in a study just released by the NEJM (Full disclosure, I’m one of the authors of this work). “Dependent Coverage under the ACA and Medicaid Coverage for Childbirth.”

    Go read it. And read more by me about it over at the AcademyHealth blog!

    @aaronecarroll
    a>

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  • AcademyHealth: Medicaid spending on health care for children

    We spend a lot of time discussing health care spending for adults, especially the elderly. Some argue that’s because we spend the majority of money on those populations. But as a pediatrician, parent, and health services researcher, I sometimes get annoyed at our lack of attention to children. Luckily, I subscribe to some journals that focus on children. From Pediatrics, “Comparison of Health Care Spending and Utilization Among Children With Medicaid Insurance“:

    Go read about this paper, and how it fits into what we know about Medicaid spending in my latest post over at the AcademyHealth blog!

    @aaronecarroll

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  • “Highly regarded” (Read Mark Hall)

    I have high regard for Nicholas Bagley. So when he sends me something with an endorsement, I pay attention. Today, he sent me a link to a paper on Medcaid and Medicaid expansion by Mark Hall, which includes this passage:

    Some conservative policy advocates claim either that people are worse off being on Medicaid than being uninsured, or that they would be substantially better off if the government fundamentally restructured Medicaid or replaced it with an entirely different program.[50] The implausible (if not preposterous) argument that people are worse off with Medicaid than with nothing at all rests on a handful of studies reporting that Medicaid patients do worse in some particular medical settings than do uninsured patients.[51] Highly regarded health economist Austin Frakt has thoroughly and convincingly debunked these studies, and this entire line of argument, as follows.[52]

    Frakt explains that observational studies that compare uninsured people with those covered by Medicaid are completely inadequate for drawing conclusions about whether Medicaid coverage causes worse health.[53] This is because people do not sort themselves randomly between insurance conditions.[54] All else being equal, sick people are more likely to seek out insurance, including Medicaid.[55] As a result, uninsured people are, in general, substantially healthier than people with Medicaid.[56] Therefore, it is almost certainly spurious to conclude that Medicaid is the cause of the worse health observed in those whom it covers.

    I’m flattered. Nick has high regard for Mark, as do I, writing me that he thinks he’s “among the best health law scholars in the country, if not the very best.”

    The work Mark cites by me is coauthored by Aaron, Harold Pollack, and Uwe Reinhardt, all highly regarded as well. Click through for the details. It appears to have been published in 2014, but I don’t recall having seen it.

    @afrakt

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  • What’s the Value of Medicaid? Who Really Benefits?

    Harold Pollack, Timothy Jost, and I have a piece in The American Prospect about why we need Medicaid and how we should improve it.

    We discuss an important NBER paper by Amy Finkelstein and her colleagues that tried to measure how much Medicaid is worth to those who receive it. The authors used data from the Oregon Health Insurance Experiment. The headline findings were that

    1. Uninsured people who get Medicaid only gained from 20 to 40 cents in value from each dollar spent by the government.
    2. A principal reason why the benefit of getting insured was so small is that when uninsured people received care, they typically paid only 20 cents on the dollar for those services. Safety-net providers, state or local government, friends, relatives, or someone else absorbed the remaining costs.
    3. Because a large fraction of Medicaid expenditures financed care that recipients would have received anyway (for example, by leaving bad debt at hospitals), it is unclear whether recipients themselves would have been willing to pay the full costs of Medicaid.

    Finkelstein and her colleagues were careful not to draw normative conclusions from these findings. But some Medicaid critics have argued, first, that Medicaid is an inefficient way to benefit the poor. If a Medicaid dollar results in only 20 cents in benefit to a previously uninsured person, wouldn’t it be more efficient to simply give that person a dollar? And, second, Medicaid is actually a subsidy for people other than those it ostensibly helps.

    We see matters differently. One important reason why the value of Medicaid appears to be so low is that Finkelstein put a much lower value on the health of Medicaid recipients than is typically used in valuations of the health of other Americans. We also argue that in many cases, we should not be troubled that Medicaid payments are going to third parties who are, after all, providing care to Medicaid recipients.

    Please read the whole thing.

    @Bill_Gardner

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