Bills
| 3.23.22

Should Oral Cancer Drugs be Covered at the Same Cost as Other Cancer Treatments? (H.R. 1730)

Do you support or oppose this bill?

What is H.R. 1730?

(Updated July 13, 2020)

This bill — the Cancer Drug Parity Act of 2019 — would require any health plan that provides coverage for cancer chemotherapy treatment to provide coverage for self administered anticancer medication at a cost no less favorable than the cost of IV, port administered, or injected anticancer medications.

Argument in favor

It doesn’t make sense for oral cancer treatments to be covered by a different part of patients’ health insurances from other cancer treatments, especially when this difference in coverage leads to big differences in cost for patients, as well. Treatment efficacy, not price, should be the deciding factor when patients are choosing between life-saving treatments.

Argument opposed

“Oral parity” laws’ effectiveness seems to be mixed, based on available evidence. Additionally, policies like this don’t address the root cause of high healthcare costs in the U.S.: high drug prices. Rather than quibbling about how insurance covers extremely expensive drugs, it’d be a better use of Congress’s time to figure out how to make drugs more affordable, period.

Impact

Cancer patients; oral cancer treatments; cancer treatment; health insurance plans; pharmaceutical benefits; and medical benefits.

Cost of H.R. 1730

A CBO cost estimate is unavailable.

Additional Info

In-Depth: Rep. Brian Higgins (D-NY), Chair of the House Cancer Caucus, introduced this bill to require health insurance plans that cover intravenous and injectable cancer medications to also cover orally administered cancer medications at the equivalent rate:

“Innovative research has led to more effective and accessible treatment options for Cancer patients, but insurance coverage hasn’t kept pace. The Cancer Drug Parity Act, levels the costs, allowing patients and doctors, not insurance companies, to decide the best course of treatment, removing the cost discrepancy as a factor in cancer care.”

In a letter to his Congressional colleagues seeking cosponsors for this bill, Rep. Higgins expounded upon the need for this bill:

“[D]espite the fact that oral chemotherapy is popular with oncologists and patients, this legislation is needed because health insurance coverage for different types of cancer treatments often is not uniform. While intravenous treatments are usually covered under a plan’s medical benefit component, orally-administered anti-cancer medications are covered under a plan’s prescription drug component which often places a higher percentage of cost-sharing on the patient. This considerable disparity in coverage can leave cancer patients to make difficult decisions on what type of care they will receive based on the outdated guidelines of their health insurance policy, rather than the advice of their doctor. Studies have consistently shown that, when faced with high co-pays for orally administered anti-cancer drugs, some patients choose to simply not fill a prescription. Ensuring parity in coverage would both increase access to life-saving treatments and improve the quality of life for cancer patients. While America continues to set an example for the world in biomedical research, Americans will struggle to gain access to these new discoveries if insurance coverage does not keep up with the science. This legislation prepares us for the next generation of cancer treatments.”

Original cosponsor Rep. Brett Guthrie (R-KY) adds:

“Due to great innovation, many cancer treatments can now be taken orally by a patient themselves, and I believe we must ensure these patients have full access to these important drugs. Americans suffering from cancer should not have to choose between one treatment option or another based on how their insurance classifies each treatment. The Cancer Drug Parity Act will fix the discrepancy between cancer treatment drugs that are orally administered and those that are intravenously or injected and will allow patients and doctors to choose the treatment that is right and most effective for them.”

The Leukemia & Lymphoma Society is one of a number of organizations that supports this bill. Louis J. DeGennaro, Ph.D., the organization’s president and CEO, says:

“Pioneering research in precision medicine is transforming the way cancer is treated. Even with these breakthroughs, far too many cancer patients face burdensome out-of-pocket costs and cannot access their treatments because insurance rules have not kept pace with innovation. The Cancer Drug Parity Act will ensure that patients across the country experience the same cost-sharing for all cancer treatments, allowing cancer patients to have equal access to the treatments recommended by their physicians. The Leukemia & Lymphoma Society applauds Representative Higgins, Representative Guthrie, Representative Matsui and Representative Bilirakis for their leadership on behalf of cancer patients and looks forward to working with Congress to move this important bill forward.”

Oral parity’s critics argue that it doesn’t address cancer drugs’ high costs, leaving health insurers to deal with those costs by increasing premiums. However, The Leukemia and Lymphoma Society argues that this simply isn’t true, as “in the 43 states with an oral parity law, cancer patients have seen their costs go down without any evidence that parity has increased premiums for other plan holders.”

Some data on oral parity laws’ effectiveness suggests that legislative effects are, at best, only a partial solution. A November 2017 study by Dr. Stacie B. Dusetzina, Ph.D., of Vandervilt University School of Medicine, and colleagues found only “modest” improvement in financial protection for patients in states with parity laws. Dr. Dusetzina said, “We found really mixed results for the effectiveness of parity legislation. For most people it decreased [out of pocket] spending, but strangely it increased spending for those with the higher cost-sharing levels.”

The late Princeton health economist Uwe Reinhardt, Ph.D. and authors memorably suggested that the high cost of healthcare — including oral cancer drugs — in the U..S. is because, “It’s the prices, stupid.” In this vein, some researchers and clinicians suggest that the real answer to oral parity lies in lower oncology drug prices overall. They contend that any other efforts are just serving to shift the burden of costs to insurers, who’ll ultimately pass along increased costs along to policyholders in the form of increased premiums. America’s Health Insurance Plans (AHIP) subscribes to this view. Its director of communications, Cathryn Donaldson, says:

“We need to find ways to bring the ever-increasing prices of prescriptions under control. Health plans are committed to ensuring that patients have access to medications that are safe, effective, and affordable. However, oral-parity legislation would place an arbitrary limit on cost-sharing between medical and pharmacy benefits, forcing premiums to increase for all consumers as a result – not just those who would use oral chemotherapy.”

This bill has 33 bipartisan House cosponsors, including 17 Democrats and 16 Republicans, in the 116th Congress. A Senate version, sponsored by Sen. Tina Smith (D-MN), has nine bipartisan Senate cosponsors, including five Republicans and four Democrats.

In the 115th Congress, the House version of this bill, sponsored by Rep. Lance Leonard (R-NJ), had 175 bipartisan cosponsors, including 90 Democrats and 85 Republicans, and didn’t receive a committee vote. A Senate version, sponsored by Sen. Tina Smith (D-MN), had five bipartisan cosponsors, including three Democrats and two Republicans, and didn’t receive a committee vote.

This bill has the support of the Lymphoma Research Foundation (LRF), American Cancer Society Cancer Action Network, American Society of Hematology, American Society of Clinical Oncology, National Brain Tumor Society, Susan G. Komen, and numerous other organizations.


Of Note: New, targeted drug therapies for cancer — many of which come in pill rather than intravenous form — have transformed a cancer diagnosis from a death sentence to a manageable chronic disease for many Americans with leukemia, lymphoma, or myeloma. For patients with certain cancers, these oral drugs are the only treatments available for their specific cancers.

Rep. Higgins’ office notes, “Oral chemotherapy is increasingly becoming a standard treatment option for cancer doctors and patients, representing approximately 35% of the oncology development pipeline. However, insurance coverage for cancer treatment has not kept up with science.” Under current law, traditional IV/injectable treatments are routinely covered under health insurance plans’ medical benefit components, whereas orally-administered anti-cancer medications are generally covered under the prescription drug component, often creating a considerable disparity in cost. As an example, in 2012, Dr. Brian Durie of the IMF wrote in the Journal of the American Society of Clinical Oncology that even though the purchase price of two myeloma medications was similar,“total cost per day was $48 higher for treatment with (injectable) vs. (oral) due to higher Medical management costs for (the injectable). The annual excess total cost of (the injectable) was $17,647.”

The Lymphoma Research Foundation (LRF) argues that this means “many patients are exposed to unmanageable cost sharing requirements in order to access oral cancer therapies.” In a op-ed, Terry Wilcox, cofounder and executive director of Patients Rising, a patient advocacy organization, adds that this also impacts cancer treatment overall:

“Due to a quirk in how Medicare and private insurance plans cover cancer drugs, chemotherapy in the preferred pill form costs patients thousands of dollars a month whereas intravenous drugs administered in a hospital or oncologist’s office may only require a small copay.”

In some cases, it’s reported that patients are even electing to forgo to delay treatment due to high out-of-pocket prices for oral treatments.

Over the past decade, 43 states have adopted their own oral parity by passing laws requiring more equitable cost-sharing for oral cancer drugs. These “oral parity laws” have a long track record of helping cancer patients without increasing premiums. However, state laws only apply to certain types of health plans, and don’t cover the approximately 60 percent of Americans on private insurance whose benefits are regulated by federal law.


Media:

Summary by Lorelei Yang

(Photo Credit: iStockphoto.com / FatCamera)