Stephen Evangelista: In seeking healthcare changes, Mass. puts poorest patients at risk

More than 1.2 million citizens of the Commonwealth of Massachusetts suffer from arthritis. Many of them may soon be unable to manage their joint pain.

That’s because state officials want to limit which medications doctors can prescribe to nearly 2 million beneficiaries of MassHealth, the state’s Medicaid program. Officials are also threatening to increase MassHealth beneficiaries’ out-of-pocket costs.

These alterations threaten patients’ access to care. The changes would be especially harmful for those living with chronic diseases.

Officials are seeking a waiver from the federal government to implement these changes because they want to constrain Medicaid costs. Currently, MassHealth comprises a whopping 41 percent of Massachusetts’ budget. Over the next year, spending is poised to increase by $322 million.

But their proposed changes would hurt patients — and might not even save money.

Officials plan to shift low-income adults from Medicaid to the state’s Affordable Care Act insurance exchange. Right now, out-of-pocket costs for Medicaid beneficiaries are capped at 5 percent of their annual income. That means a MassHealth beneficiary earning $16,600, or 138 percent of the federal poverty level, would pay a maximum of $830 in co-pays.

But if the person is moved to an exchange plan, he’d be expected to cough up $1,250 per year in out-of-pocket costs. That’s a roughly 50 percent increase in health expenses for some of our poorest residents. Massachusetts has proposed to lower cost sharing in the exchange, but that proposal requires additional approval.

Many Medicaid beneficiaries — especially those living with chronic conditions like arthritis — won’t be able to afford the increased expenses and will skip treatments. They’d become sicker as a result.

Many would no longer be able to work. Adults with rheumatoid arthritis are 53 percent less likely to be employed than adults not suffering from the disease. Some people with uncontrolled chronic conditions would require hospitalization.

In other words, the resulting increase in hospital spending and lost productivity could cost, rather than save, Massachusetts money.

The proposed changes would also directly limit these patients’ access to medicine. Currently, federal law stipulates that drug companies that participate in state Medicaid programs like MassHealth must discount their medicines by at least 23 percent. Drug companies generally offer discounts of nearly twice that amount, saving Medicaid billions of dollars.

But as long as medicines are discounted at least 23 percent, Medicaid programs have to cover them.

Massachusetts officials plan to erase this guarantee. They want to shrink MassHealth’s list of drugs that physicians can prescribe. They promise the new list will include “at least” one drug per therapeutic class. There is no “one size fits all” formula in prescribing drugs.

State officials believe covering just one medicine per class will give them leverage to extract even bigger discounts from drug companies. They either don’t realize, or don’t care, that the change will restrict patients’ treatment options.

Consider an arthritis sufferer who needs a steroid to treat his or her condition, but is allergic to cortisone. Under this new MassHealth, cortisone could be the sole steroid covered. The patient would have to work through a complicated exception process to access another medicine, or simply let her arthritis go untreated, as MassHealth beneficiaries are unlikely to have the resources to pay completely out-of-pocket for medicines.

Many MassHealth beneficiaries take multiple drugs to treat several chronic conditions. Not all drugs interact well with each other. Limiting drug coverage to one medicine per therapeutic class would prevent doctors from prescribing the combination of treatments that works best for each patient.

Eliminating healthcare options and dramatically raising out-of-pocket expenses for poor patients will endanger their health and potentially increase state spending. If Massachusetts officials proceed with their waiver request, millions of the state’s most vulnerable residents could lose access to care.

Stephen Evangelista is the former President and CEO of the Arthritis Foundation, New England region.