New CMS Rule Threatens the Bipartisan Compromise to Protect Those with Preexisting Conditions

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In the wide ideological gulf between Democrat and Republican healthcare reform efforts — with "Medicare For All" at one end and a market-based system at the other — there has emerged one bipartisan point of agreement: Those with preexisting conditions must be protected. Even those Republicans who want to wholly repeal Obamacare don't want to return the days when insurers could deny applicants coverage because they had cancer.

That's what makes a new rule proposed in November by the Trump Administration's Center for Medicare & Medicaid Services so disappointing. In an effort to trim healthcare costs, the rule would allow Medicare Part D plans, which cover roughly 45 million Americans, to exclude some prescription drugs that are saving the lives of countless patients with rare and chronic conditions.

Currently, Part D plans are required to cover "all or substantially all" prescription drugs in six protected classes, including those that treat HIV, cancer, and depression. This requirement gives the sickest and most vulnerable patients peace of mind that they will have a full cupboard of pharmaceutical treatment options available. 

Yet If implemented, the proposed rule would allow Part D plans to deny covering drugs if they don't offer significant innovation over existing ones, or if their prices rise faster than inflation. The rule would also usher in "step therapy," which requires that patients adhere to a checklist of drugs, along with other measures that curb prescription drug choices. In short, the rule would sometimes deny desired prescription drug access to those who need it most.

This reform amounts to a one-size fits all solution to the remarkably individualistic process of prescription medicine. For reasons that scientists still don't fully understand, similar patients often respond differently to the same drug. While some patients flourish, others have mediocre outcomes at best and significant side effects at worst. That's why it's so important to allow the sickest patients access to a variety of medications, and put prescription decisions in the hands of patients and physicians rather than government and insurance company bureaucrats. 

With the right prescription drug regimen, even patients with serious and chronic conditions can enjoy a high quality of life. Disrupting their drug regimen plays Russian Roulette with their treatment. Even a brief interruption in effective treatment can significantly worsen health outcomes. 

This is especially true for patients suffering from conditions in these six protected classes. Take depression and mental illness — which some experts believe to be approaching epidemic levels. Despite what the Prozac craze of the 1990s may have led many to understand, there is no silver bullet therapy for these devastating conditions. Successful treatment usually depends on the freedom to experiment with a variety and combination of medications. While Wellbutrin and Zoloft may work for one patient, Lithium and Lexapro may work better for another. 

Same story with HIV, cancer, and other rare diseases, which are no longer death sentences but whose treatments often take time to fine-tune for maximum effectiveness and minimum side-effects. Limiting patients' prescription drug options takes arrows out of their treatment quiver.

Potentially the biggest consequence of this proposal is that it threatens the drug research pipeline because drug makers cannot guarantee that if they develop a new drug they will be able to profitably bring it to market. According to a paper by the National Bureau of Economic Research, prescription drug controls like those proposed in this rule lead to fewer research and development projects being undertaken. 

To be sure, prescription drug cost concerns are significant. It's just that for many patients with the most serious conditions, the research pipeline is often their only hope.  

The kicker? This collectivist solution likely won't even achieve its stated aim of controlling spiraling healthcare costs because the savings achieved in Part D would be offset by additional inpatient and emergency room costs in Part A and Part B. A study out of Northwestern University and the University of Texas finds that covering drugs less generously in Part D ends up costing traditional Medicare $475 million per year in corresponding medical complication and hospitalization costs. A Pew report explains that a “lack of adequate access to medications can in some circumstances increase costs to other Medicare programs through increased hospitalizations from complications or increased physician visits to manage medications.”

In today's era of unprecedented political polarization, bipartisan policy compromise like the one around protecting healthcare access for those with preexisting conditions should be taken even more seriously. This CMS rule should therefore be cause for bipartisan alarm. 

Terry Wilcox is the co-founder and executive director of Patients Rising. 


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