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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.
The panel also discussed Section 1332 waivers, which waive certain requirements of the Affordable Care Act (ACA) and allow states to pursue alternative coverage approaches in the exchanges and small group markets that are consistent with the goals of the ACA.

The Trump administration has fostered a broader interpretation of these waivers, providing states more leeway in developing initiatives. According to Schaefer, there are multiple states that have now used 1332 waivers to do risk adjustment, including by using funding that goes to the subsidies within the exchanges and target them to insurance plans that have high-risk and high-cost populations.

How often and in which ways these waivers are used going forward will likely depend on the result of ongoing litigation involving the ACA, explained Walters. In December, a federal judge in Texas ruled that the ACA’s individual mandate is unconstitutional and that the rest of the law must also fall. In March, the Department of Justice backed the ruling.

However, even if the entire legislation is struck down, innovation waivers like 1332 waivers will continue, argued Walters.

“They may not have the strength of the ACA, but this is an ongoing effort to give states much more authority and leeway to design what’s important for that particular state,” he said.

Bob Donnelly, MPP, senior director of Health Policy, Johnson & Johnson, also commented, noting that ongoing efforts to erode the ACA are important as we now have a system that offers broader access to short-term limited duration health plans outside of what the ACA envisioned, which can create issues when it comes to benefits and the impact on risk pools.

Sticking with the subject, Schaefer argued that these plans offer opportunities for those getting “squeezed out of the current system,” including many middle-class families who don’t receive subsidies and are leaving the market altogether as healthcare costs and premiums continue to rise. States have been on the frontline of this, seeing firsthand how people in their state can’t afford coverage, said Schaefer, who added that short-term limited duration plans provide immediate relief to these types of consumers. However, she predicted that associated health plans and health reimbursement accounts will be more popular than these plans because of how limited they are.

While beneficial for some consumers, these plans are offered to everyone, said Brooks-Coley, arguing that consumers will often times buy into these plans not truly understanding what they are and what they offer. Consumers will buy plans thinking they will be cheaper and then get stuck with high out-of-pocket costs after getting sick with cancer, she said.

Rounding up the conversation, the panel touched briefly on value-based contracts, which have been touted as a way to address the high costs of cancer drugs, among others.

“There are still a lot of nuances to value-based contracting that people have to get experience in exactly how to do it. Intuitively, it seems very easy to do until you get into all the details and it gets complicated very quickly,” said Walters.

Donnelly agreed, adding that it is early in the playing field and that evaluation of these contracts is just as important as actually doing them so that states can learn what works and what doesn’t.

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