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Shifting Regulatory Action to States: Implications for Patient Access to High-Quality Cancer Care

Jaime Rosenberg
Last week, a panel of diverse stakeholders took the stage at the National Comprehensive Cancer Network Policy Summit in Washington, DC, to discuss shifting regulatory action from the federal to the state level, and the possible implications for patient access to high-quality cancer care.
Since taking office, the Trump administration has been granting states greater flexibility in how it addresses healthcare for its populations, including through Medicaid work requirements, block grants, and short-term limited duration health plans.

Last week, a panel of diverse stakeholders took the stage at the National Comprehensive Cancer Network Policy Summit in Washington, DC, to discuss how shifting regulatory action from the federal to the state level poses implications for patient access to high-quality cancer care.

The panel kicked off the discussion by outlining how Medicaid Section 1115 waivers have been leveraged by states to initiate different types of demonstration and research projects, such as Medicaid expansion and, more recently, Medicaid work requirements for certain populations.

“I think it’s a larger trend of states looking at really beginning to diversify the Medicaid population more and to say, ‘We want to look at populations differently,’” said Nina Owcharenko Schaefer, senior research fellow at The Heritage Foundation. “Rather than having Medicaid as one program where we deliver [healthcare] to everyone, I think what we’re seeing is states taking a very active role in understanding the needs of the patients in Medicaid are very different from one another, and that not every one Medicaid patient is the same as another Medicaid patient.”

A number of states have looked at different ways to diversify their programs, including by looking at cost-sharing for some of the higher income levels in Medicaid, addressing behavioral health, and looking beyond the medical scope to alternative services.

“From the patient perspective, flexibility is important and innovation is important; however, the concern, and we try to make sure there’s a clear balance, is the fact that you have to have flexibility but also make sure that patient access and access to quality care is not harmed,” said Keysha Brooks-Coley, MA, vice president of Federal Advocacy and Strategic Alliances American Cancer Society Cancer Action Network, who noted that Medicaid work requirements, in particular, could hinder access for patients with cancer.

The panel also discussed block grants, which have not yet seen as much uptake as work requirements. In March, President Trump released his budget for fiscal year 2020, which called for converting Medicaid to a system of block grants. On July 1, a law went into effect in Tennessee that directed the governor to submit a waiver to CMS to turn the state’s Medicaid program into a block grant. If approved, Tennessee would become the first state to make the transition.

Block grants represent the conclusion that states should figure out what best serves the needs of their populations, said Ronald S. Walters, MD, MBA, MHA, Department of Breast Medical Oncology, Division of Cancer Medicine, MD Anderson Cancer Center, who added that the idea makes sense as long as there are some guardrails built around it to make sure essential health benefits, among other things, are protected.

“States balance their budgets, so they are squeezed in figuring out how to take that dollar and make it spread everywhere,” said Schaefer. “You know where they don’t balance their budget? Here in Washington.”

Consequently, she said, states shift additional costs to the federal government. Block grants are one way that will put the federal government on a more reliable and consistent budget cycle. Some states are also in favor of block grants because they like the idea of having the freedom to use funding how they see fit, even if it means a different style of funding, she said.

Brooks-Coley pushed back, arguing that there are a lot of concerns from the patient perspective. She posed the question of what happens when states run out of money or don’t have enough money to provide certain care for their populations?  

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