Oregon's Medicaid waiver hurts chronic disease patients

By Kenneth E. Thorpe
February 3, 2022

More than half of Oregon's population -- nearly 2.3 million people -- is living with at least one chronic disease.^{^[1]}^{^[2]} A disproportionate share rely on Medicaid to provide them the medications they need, and are beneficiaries because of income constraints and disability, especially children.^{^[3]}

That's why a recent state proposal is so troubling. In February, the Oregon Health Authority plans to request a federal waiver that would, among other things, allow it to deny coverage of certain drugs under the state's Medicaid program.^{^[4]}

Though the stated goals of the waiver are aimed at advancing health equity, it would only further disadvantage the state's most vulnerable Medicaid enrollees.

The proposal would do so in two ways. First, it would allow Oregon to establish a "closed formulary," which could restrict Medicaid coverage to just one drug for each therapeutic class of medicines for adults. In other words, the state's Medicaid program would only have to cover one antidepressant, one blood thinner, one arthritis medicine -- assuming any drug will do regardless of the severity of illness, any contra-indications, or doctor recommendations.

That alone ignores the reality that up to 62% of adult Medicaid beneficiaries are living with one or more chronic conditions.^{^[5]} These patients often require complex treatment regimens, making it imperative that they have different medications to choose from, since no two drugs work the same for every patient.^{^[6]} Without access to more than one medication, the health of chronic disease patients, especially those managing multiple chronic conditions, will undoubtedly decline.

Second, the waiver would restrict access to treatments that the Oregon Health Authority deems to have "little or inadequate evidence of clinical efficacy."^{^[7]}^{^[8]}

To the uninitiated, that sounds sensible.

But what that means, in practice, is that Oregon will limit patients' access to drugs approved through the Food and Drug Administration's accelerated approval pathway.^{^[9]} This will be especially devastating for patients battling serious illnesses with limited or no treatment options.

The accelerated approval pathway is a critical source of novel therapeutics for patients with rare or life-threatening chronic conditions. Of the 250 drugs granted accelerated approval since the program's inception in 1992, 42% treat serious or life-threatening rare diseases and 65% treat cancers with limited to no other treatment options.^{^[10]} Without access to these medications, Oregonians who rely on Medicaid for their chronic disease treatments will face longer odds of survival.

According to the state's waiver proposal, it hopes to "avoid exorbitant spending on high-cost drugs that are not medically necessary."^{^[11]}

However, making this sort of value judgement based on cost is entirely flawed, since drugs granted accelerated approval have not in fact dramatically increased Medicaid costs. A recent analysis revealed that accelerated approval medications accounted for less than 1% of U.S. Medicaid spending each year between 2007 and 2018.^{^[12]}

Taken together, these actions would only further exacerbate the barriers to health facing chronic disease patients -- particularly Oregonians of color, who account for more than 35% -- nearly 420,000 -- of the state's Medicaid enrollees.^{^[13]} ^{^[14]}^{^[15]}

Diabetes, cardiovascular disease, many cancers, and a number of other chronic conditions disproportionately affect people of color – not only in higher prevalence, but also in terms of poorer health outcomes. Erecting additional barriers to access the treatments needed to prevent the onset and progression of these serious illnesses will exacerbate health inequity in Oregon -- not alleviate it. Ensuring these patients -- and all those with a chronic disease -- have access to the treatments they need to achieve better health is necessary to achieving true health equity.

Clearly this proposal is shortsighted in many ways, and for the sake of continuing progress against health inequities and avoiding the tragic precedent that this could set, the time is now for voices across the state to speak up against the Oregon 1115 waiver request.

Kenneth E. Thorpe is a professor of health policy at Emory University and chairman of the Partnership to Fight Chronic Disease.