Access to Health Care

ACS CAN advocates for policies that provide access to treatments and services people with cancer need for their care - including those who may be newly diagnosed, in active treatment and cancer survivors.

Access to Health Care Resources:

ACS CAN responded to the reopening of the Centers for Medicare and Medicaid Services (CMS) coverage decision for NGS testing panels.  ACS CAN comments stressed that the existing coverage framework improperly freezes coverage based on current science rather than allowing a framework that could evo

ACS CAN is concerned that over the past year, policymakers and the administration have taken several legislative and regulatory actions that could make it harder for individuals with pre-existing conditions to obtain health insurance coverage that is adequate, affordable, and available, thereby jeopardizing access to life-sustaining care.

Where healthcare dollars are spent compared with dollars on cancer care, 2015.

ACS CAN submitted comments regarding Alabama's proposed plan year 2020 Essential Health Benefit Benchmark Revisions.

ACS CAN submitted comments regarding New Jersey's request for a 1332 waiver to create a reinsurance program.

ACS CAN is very concerned about proposed policy changes that would move coverage of cancer and supportive care drugs from Part B to Part D. Proposed policy changes could jeopardize patient access to drugs, create potential safety issues, and increase out-of-pocket costs for patients who already struggle to afford cancer treatment under the current Medicare program.

In 2003, Congress passed the Medicare Modernization Act (MMA), which created an outpatient prescription drug benefit in the Medicare program. Known as Part D, the prescription benefit is operated exclusively through private insurance plans that contract with Medicare. To ensure that beneficiaries have coverage for the drugs they need Part D plans are required to cover at least two drugs in each therapeutic class. A therapeutic class is a group of medications that are used to treat the same condition. 

ACS CAN submitted comments regarding the CMS Innovation Center's request for information on a new direction.

Workforce Resources:

These comments submitted to the Institute of Medicine’s Committee on the Governance and Financing of Graduate Medical Education address ways to ensure an adequate and appropriate cancer care workforce to treat cancer patients.

Prescription Drug Affordability Resources:

Many cancer patients have difficulty affording the cost of their prescription drugs, regardless of whether they are insured.  This is especially true for newer drugs that do not have a generic equivalent.  Many programs exist to help patients afford their medication.  This fact sheet focuses on two of these – patient assistance programs and discount coupons.  

Biological drugs, commonly referred to as biologics, are a class of drugs that are produced using a living system, such as a microorganism, plant cell, or animal cell. Like all drugs, biologics are regulated by the United States Food and Drug Administration (FDA).

Pharmacy benefit managers (PBMs) are entities that administer prescription drug programs for many private, public, and employer health insurance plans. PBMs establish pharmacy networks, negotiate prices with pharmaceutical manufacturers on behalf of their clients, and provide basic claims administration.

For an individual with specific health care needs – like cancer patients and survivors – the drugs covered by a health plan and corresponding cost sharing for each drug is important information when choosing health insurance. However, to make an informed choice, formulary information must be disclosed to the individual.

Prescription drugs are often less expensive in other countries. This is due to a variety of factors. There have been efforts at the state and federal level to allow individuals to purchase lower cost prescription drugs from other countries and import these products into the United States for personal use.

New breakthroughs in cancer research are making more life-saving drug therapies available. Keeping these therapies affordable for patients is imperative. Prohibitive cost sharing for prescription drugs can cause patients to skip dosages, split pills or stop taking their medications entirely, which reduces the effectiveness of their treatment.

Currently, Medicare part D is administered entirely by private plans that follow guidelines set by CMS. Policymakers propose allowing the Secretary of Health and Human Services to enter negotiations between pharmaceutical manufacturers and Part D plans in an attempt to lower prescription drug prices.

Most health insurance plans that cover prescription drugs use formularies to categorize the drugs the plan will cover and determine the amount of patient cost sharing. Divided into “tiers”, the higher the tier, the higher the share of cost for patients.

Private Health Insurance Resources:

Last year, the Administrative finalized a regulation that expands access to short-term, limited-duration insurance products.

ACS CAN submitted comments regarding the 2020 Proposed Notice of Benefit & Payment Parameters for the individual insurance market.

ACS CAN submitted comments on the proposed 2019 CMS Program Integrity Rule.

Medicare Resources:

Letter in support of Medicare coverage for CAR-T therapies.  

ACS CAN submitted comments on the Medicare Part C and D Rule.

Approximately 1.7 million new cancer cases are expected to be diagnosed in 2018.[1] Age is one of the most important risk factors for cancer, with one half of cancer cases occurring in people over the age of 65.

On January 16, 2018, ACS CAN filed comments in response to CMS’ proposed rule implementing changes to the Medicare Part C and Part D programs. ACS CAN commented on a number of proposed policies:

ACS CAN submitted comments regarding the Centers for Medicare and Medicaid Services' Survey called Innovation Center New Direction.

ACS CAN submitted comments supporting CMS' propsoal related to CMS' laboratory date of service policy.

In our comments on the CY 2018 Medicare Physician Fee Schedule proposed rule, ACS CAN expressed support for CMS’ proposed changes that would allow federally qualified health centers to provide more care coordination, and urged CMS to provide even more flexibility than proposed.

Disparities Resources:

On November 10, 2015, ACS CAN hosted the first National Summit on Health Equity in St. Louis, Missouri.

The National Institutes of Health (NIH) and the National Cancer Institute (NCI) are the foundation of our national  cancer research program and support research in every state. Today, that program is making remarkable progress in every area of discovery to improve cancer prevention, early detection, treatment, and care.

Health Care Delivery Resources:

"Surprise billing” is when an insured patient is unknowingly treated by an out-of-network provider and is then billed the difference between what the provider charged, and what the insurer paid. Surprise bills can be significantly higher than the consumer’s standard in-network cost-sharing. 

Many patients with complex diseases like cancer find it difficult to afford their treatments – even when they have health insurance.  Current law establishes a limit on what most private insurance plans can require enrollees to pay in out-of-pocket costs.  These limits protect patients from extremely high costs and are essential to any health care system that works for cancer patients and survivors.

 

The Affordable Care Act (ACA) helps individuals with limited incomes afford their health care coverage by
providing cost-sharing subsidies (like deductibles, coinsurance, and copayments) for silver-level plans
purchased on the health insurance marketplaces. Currently, Congress and the administration are
debating whether to continue funding these cost-sharing reduction subsidies (CSRs). If CSR subsidy
funding is discontinued, health care costs could increase for all marketplace enrollees – regardless of
whether the enrollee qualifies for the CSRs.

This report explores the experiences of cancer patients with their health insurance and financial challenges through interviews with hospital-based financial navigators. The report finds that while the Affordable Care Act has brought crucial improvements to patient access to health insurance, cancer patients still face serious challenges affording their care and using their insurance benefits.

Congressional efforts to repeal and replace the Affordable Care Act have included additional funding in an effort to stabilize state individual insurance markets.  The funding level proposed is inadequate, as discussed in more detail in this backgrounder.

Numerous provisions of H.R. 1628, the American Health Care Act (AHCA), would adversely impact access to adequate and affordable health insurance coverage for cancer patients and survivors.

On April 25, 2017, the text of an amendment to the American Health Care Act (AHCA) to be offered by Representative MacArthur (R-NJ) was released.  The amendment could undo several key protections that are critical for cancer patients and survivors – including the prohibition on pre-existing condition exclusions.

As Congress debates enacting changes to the health care market, one concept re-emerging is state high-risk pools to provide health insurance coverage for individuals who otherwise cannot obtain or afford coverage. High risk pools are not a new concept. Prior to the enactment of the Affordable Care Act (ACA) many states operated some form of high risk pool. During implementation of the ACA, a federal high risk pool was established as an interim step to the new marketplaces. The overall success of high risk pools varied. This fact sheet examines how state risk pools work and the impact on persons with cancer and cancer survivors.

Current federal requirements prohibit health insurance plans from denying coverage to individuals with pre-existing conditions like cancer.  These are one of several important patient protections that must be part of any health care system that works for cancer patients.

Medicaid Resources:

ACS CAN Comments on Montana's 1115 Demonstration Waiver.

ACS CAN Comments on Utah's 1115 Demonstration Waiver

ACS CAN CMS Comments on New Mexico's 1115 Demonstration Waiver

ACS CAN CMS Comments on South Carolina's 1115 Demonstration Waiver

ACS CAN CMS Comments on Tennessee's 1115 Demonstration Waiver

A Section 1115 Demonstration Waiver gives states flexibility to design and improve upon their Medicaid programs through pilot or demonstrations projects.

ACS CAN submitted comments on the proposed Medicaid and Children's Health Insurance Plan Managed Care rule.

ACS CAN CMS Comments on Virginia's 1115 Demonstration Waiver

ACS CAN CMS Comments on Michigan's 1115 Demonstration Waiver