As of Oct. 1, Oregons Medicaid program stopped covering major medical interventions for patients assessed as having two years or less to live. Not only is the move immoral, its likely illegal.
This coverage restriction comes courtesy of the states Health Evidence Review Commission, which is charged with squeezing savings out of public insurance programs such as Medicaid.
Earlier this year, the HERC enacted an old, much-maligned Medicaid proposal called Guideline 12. Guideline 12 allows public insurance dollars to underwrite palliative treatments for end-of-life patients to reduce pain and suffering.
But any drug, surgery or other medical intervention classified as curative that is, aimed at prolonging survival isnt covered.
In other words, Oregons Medicaid program will pay to help its 644,000 enrollees die, but not to live.
Federal law limits Medicaid eligibility to those with incomes below 133 percent of the federal poverty line. Thats just over $15,000 for a single person.
Advanced treatments for cancer, heart disease, Alzheimers and other serious conditions typically cost hundreds of thousands of dollars per year. Denying desperate Oregon Medicaid enrollees coverage of life-saving therapies effectively denies them treatment and sentences them to near-certain death.
The data propping up Guideline 12 are almost entirely related to overall survival rates, which basically measure the amount of additional life a given treatment provides to the average patient.
For instance, a stage-four metastatic breast cancer drug could be assessed to have an overall survival rate of just a few months. That doesnt sound like much and so it could seem financially imprudent for Oregons Medicaid program to spend hundreds of thousands of dollars on that drug.
But average is a useful concept only in academic investigation. In the doctors office, its a dangerous fiction.
Theres no such thing as an average patient. Individual physiology is sufficiently varied that a cancer treatment thats proven ineffective for hundreds of late-stage patients could still prove to be a lifesaver for others. Installing a one-size-fits-all prohibition will inevitably deny some people access to the very treatment that could save their lives.
Doctors, not distant government technocrats from the HERC, are best positioned to evaluate a given treatments potential to help a particular patient. Theyre the ones most familiar with variables that can impact efficacy, like medical history, genetic heritage, and co-morbidities.
In fact, physician autonomy is uniquely important in precisely the areas HERC is stepping into. Blood cancers, for instance, are dizzyingly complex. Doctors have to customize their treatment regimens accordingly.
Sometimes, this process involves enrolling a patient in a clinical trial for an innovative new therapy. Such a long shot can pay off in years, even decades, of additional life.
Little wonder, then, that one of the premier cancer treatment facilities in the state, the Eugene-based Willamette Valley Cancer Institute and Research Center, has vigorously opposed implementation of Guideline 12. As the institute puts it, Patients deserve treatment that is available based on the best evidence, not on a timeline.
HERCs Medicaid restrictions arent just bad medicine they may even be illegal. The Affordable Care Act President Obamas 2010 health care reform law includes a provision prohibiting public insurance programs from discriminating against patients on the basis of health status or diagnosis.
Section 1302 of the law explicitly states that essential health benefits should not be subject to denial to individuals against their wishes on the basis of the individuals age or expected length of life.
Only one agency has the authority to override the HERC, rescind Guideline 12, and ensure Oregons most desperate patients continue to have access to needed therapies: the federal Centers for Medicare and Medicaid Services.
CMS needs to step in. Oregon has made a deadly misstep with these new Medicaid rules. Oregonians shouldnt stand for state officials rationing life-saving care for their fellow citizens.