Denying care? Concerns with Oregon's Medicaid coverage guidelines

When a document guiding health coverage decisions contains the word "survival" and the phrase "not a covered service," it definitely warrants a closer look, and what we see in a set of coverage guidelines from Oregon Medicaid officials is disturbing to say the least.

In August, Oregon's Health Evidence Review Commission approved a set of Medicaid guidelines addressing "Treatment of Cancer Near the End of Life." What the guidelines do is set a series of standards that, if applied, would allow Medicaid to withhold coverage of cancer treatments for some of the state's most vulnerable citizens.

This is deeply troubling on a number of fronts:

  • It is difficult, if not impossible, to defend the Oregon guidelines on a moral and ethical basis. Yes, states are facing difficult financial challenges, in many cases because of escalating Medicaid spending. To curb costs, though, by withholding care from our sickest and most financially disadvantaged neighbors -- those who can't possibly afford adequate medical care on their own -- is simply unconscionable.
  • The Oregon guidelines actually run afoul of federal law, specifically provisions in the Affordable Care Act. Section 1302 of the health reform law states quite clearly that "essential health benefits cannot be denied to individuals against their wishes on the basis of the individuals' age or expected length of life or of the individuals' present or predicted disability, degree of medical dependency, or quality of life." In other words, the law of the land says that healthcare cannot be denied to a patient, simply because government officials have decided that the patient is too sick to make the treatment worthwhile.
  • Finally, treating cancer patients as if they are a single homogenous group makes little sense in this era of rapidly-evolving genomic medicine. Increasingly, therapies are being tailored to an individual's genetic makeup with increasing rates of effectiveness. One simply cannot prejudge whether or not a cancer therapy will achieve a positive outcome in an individual patient.

When considering the Oregon Medicaid guidelines, there is one core question that must be answered. If a cancer therapy -- keeping in mind that new and more effective therapeutic solutions are constantly being developed -- can give a person more months or years of quality life, is it the role of the state to deny someone that therapy simply because they are poor and on Medicaid?