The American health system has experienced substantial changes over the last decade. A new phenomenon is the growing authority of states over health policies historically administered by federal policymakers. This shift, partially introduced by the Affordable Care Act’s (ACA) State Innovation Waiver provision, has been expanded considerably by the Trump administration, increasing state experimentation in network adequacy, essential health benefits, and other facets of care to unprecedented levels. Although supporters of this policy shift remark that states are, and always have been, fertile grounds for healthcare innovation, oncology stakeholders express concern for the erosion of comprehensive care across a new patchwork of state innovation projects and patient protection laws.1 To consider the implications of this development, NCCN hosted the 2019 Policy Summit: The State of Cancer Care in America: The Impact of State Policy on Access to High-Quality Cancer Care. The summit convened 2 multistakeholder panels and included a morning keynote to examine the challenges and opportunities for high-quality cancer care posed by new state authority over health policy. This article provides a technical review of the policy perspectives highlighted during summit discussions and keynote lectures.
Shifting regulatory authority from the federal government to states and the implications for patient access to high quality cancer care. Panel discussion at the NCCN Policy Summit: The State of Cancer Care in America: The Impact of State Policy on Access to High-Quality Cancer Care; June 27, 2019; Washington DC.
HHS.gov. What is the Affordable Care Act? Accessed September 25, 2019. Available at: https://www.hhs.gov/answers/affordable-care-act/what-is-the-affordable-care-act/index.html
Medicaid.gov. Section 1115 demonstrations. Accessed September 25, 2019. Available at: https://www.medicaid.gov/medicaid/section-1115-demonstrations/index.html
Neale B. Opportunities to promote work and community engagement among Medicaid beneficiaries. Accessed September 20, 2019. Available at: https://www.medicaid.gov/sites/default/files/federal-policy-guidance/downloads/smd18002.pdf
Kaiser Family Foundation. Tracking Section 1332 state innovation waivers. Accessed September 20, 2019. Available at: https://www.kff.org/health-reform/fact-sheet/tracking-section-1332-state-innovation-waivers/
Department of Health and Human Services (HHS). State relief and empowerment waivers. Accessed September 24, 2019. Available at: https://www.federalregister.gov/documents/2018/10/24/2018-23182/state-relief-and-empowerment-waivers
Centers for Medicare & Medicaid Services. Section 1332 state relief and empowerment waiver concepts: discussion paper. Accessed September 20, 2019. Available at: https://www.cms.gov/CCIIO/Programs-and-Initiatives/State-Innovation-Waivers/Downloads/Waiver-Concepts-Guidance.pdf
Sloan C, Rosacker N, Carpenter E. State-run reinsurance programs reduce ACA premiums by 19.9% on average. Accessed September 24, 2019. Available at: https://avalere.com/press-releases/state-run-reinsurance-programs-reduce-aca-premiums-by-19-9-on-average
Texas Health and Human Services. Report: independent evaluation of Texas' Uncompensated Care (UC) program and Delivery System Reform Incentive Payment (DSRIP) program. Accessed September 25, 2019. Available at: https://hhs.texas.gov/sites/default/files/documents/laws-regulations/reports-presentations/2016/eval-uncompensated-care-medicaid-payments-tx-hospitals-role-tx-uc-pool-aug-2016.pdf
Levy H, Buchmueller T. Health Michigan plan evaluation domain II – reduction in the number of uninsured. University of Michigan Institute for Healthcare Policy & Innovation. Accessed September 23, 2019. Available at: https://www.michigan.gov/documents/mdhhs/Domain_II_-_Reduction_in_Number_of_Uninsured_647135_7.pdf
Buchmueller T, Levy H, Nikpay S, Rhodes J. Healthy Michigan plan evaluation domain I – hospital uncompensated care. University of Michigan Institute for Healthcare Policy & Innovation. Accessed September 23, 2019. Available at: https://www.michigan.gov/documents/mdhhs/Domain_I_-_Reduction_in_Uncompensated_Care_647133_7.pdf
Sommers BD, Goldman AL, Blendon RJ, et al.. Medicaid work requirements — results from the first year in Arkansas. N Engl J Med 2019;381:1073–1082.
Musumeci MB, Foutz J, Garfield R. How might older nonelderly Medicaid adults with disabilities be affected by work requirements in section 1115 waivers? Accessed September 23, 2019. Available at: https://www.kff.org/medicaid/issue-brief/how-might-older-nonelderly-medicaid-adults-with-disabilities-be-affected-by-work-requirements-in-section-1115-waivers/
Keith K. The short-term, limited-duration coverage final rule: the background, the content, and what could come next. Accessed September 24, 2019. Available at: https://www.healthaffairs.org/do/10.1377/hblog20180801.169759/full/
Rudowitz R. 5 Key questions: Medicaid block grants & per capita caps. Accessed September 23, 2019. Available at: https://www.kff.org/medicaid/issue-brief/5-key-questions-medicaid-block-grants-per-capita-caps/
Trends in cancer care policy at the state level. Panel discussion at the NCCN Policy Summit: The State of Cancer Care in America: The Impact of State Policy on Access to High Quality Cancer Care; June 27, 2019; Washington, DC.
Schneider A, Searing A, Alker J, et al.. Medicaid and state budgets: checking the facts (yet again). Accessed September 26, 2019. Available at: https://ccf.georgetown.edu/2019/02/28/medicaid-and-state-budgets-checking-the-facts-yet-again/
Adamson BJ, Cohen AB, Estevez M, et al.. Affordable Care Act (ACA) Medicaid expansion impact on racial disparities in time to cancer treatment [abstract]. J Clin Oncol 2019;37(Suppl):Abstract LBA1.
Texas Alliance for Health Care. The impact of uninsurance on Texas’ economy. Accessed September 10, 2019. Available at: http://wrgh.org/docs/The_Impact_of_Uninsurance_on_Texas_Economy_20190108.pdf
Massachusetts Health Policy Commission. 2018 Report on health care cost trends. Accessed September 10, 2019. Available at: https://www.mass.gov/doc/2018-report-on-health-care-cost-trends
Fischer MA, Avorn J. Step therapy—clinical algorithms, legislation, and optimal prescribing. JAMA 2017;317:801–802.
Fink JL. Laws in 20 states address insurance-mandated step therapy. Accessed September 10, 2019. Available at: https://www.pharmacytimes.com/publications/issue/2019/july2019/laws-in-20-states-address-insurancemandated-step-therapy
National Psoriasis Foundation. Step therapy legislation by state. Accessed September 13, 2019. Available at: http://www.steptherapy.com/step-therapy-legislation-by-state/
The Ohio State Legislature. Permit health insurers to cover pharmacist-provided benefits. Accessed September 10, 2019. Available at: https://www.legislature.ohio.gov/legislation/legislation-summary?id=GA132-SB-265
Findlay S. States pass record number of laws to reel in drug prices. Accessed September 12, 2019. Available at: https://khn.org/news/states-pass-record-number-of-laws-to-reel-in-drug-prices/
Winegarden W. The ICER myth. Available at: https://static1.squarespace.com/static/5886319ba5790a66cf05d235/t/5ae0a7be575d1f3b350e155e/1524672450834/IfPA_The+ICER+Myth_April+2018+%281%29.pdf. Accessed March 2, 2020.
Zafar SY, Peppercorn JM, Schrag D, et al.. The financial toxicity of cancer treatment: a pilot study assessing out-of-pocket expenses and the insured cancer patient’s experience. Oncologist 2013;18:381–390.
National Governors Association. NGA brings together more than 100 health policy leaders to improve capacity for health care services. Accessed September 14, 2019. Available at: https://www.nga.org/news/press-releases/nga-brings-together-more-than-100-health-policy-leaders-to-improve-capacity-for-health-care-services/
Lesser M. The evolving role of states in ensuring access to high quality cancer care. Keynote at the NCCN Policy Summit: The State of Cancer Care in America: The Impact of State Policy on Access to High Quality Cancer Care; June 27, 2019; Washington, DC.
Wade K. Short-term, limited-duration health insurance policies. Bulletin HC-121. Accessed September 11, 2019. Available at: https://portal.ct.gov/-/media/CID/BulletinHC121pdf.pdf?la=en