Here are key actions the Centers for Medicare and Medicaid Services, U.S. Congress and other federal leaders must take to ensure access to quality, affordable healthcare:
Restore and Strengthen Medicaid
The Medicaid program plays a vital role for the lung health community. Almost one-fifth of people with chronic obstructive pulmonary disease (COPD) are enrolled in Medicaid or qualify as dual eligible, close to half of all children with asthma receive their healthcare coverage through Medicaid and the Children’s Health Insurance Program (CHIP) and Medicaid enrollees smoke at a rate over twice as high as privately insured individuals.
Alternative funding mechanisms that limit federal funding, such as block grants, force states to make cuts that harm beneficiaries. Congress must preserve the current FMAP Medicaid funding structure to protect access to comprehensive coverage as well as improve the ability of the program to increase support to states during public health and economic crises.
Twelve states have not expanded their Medicaid programs, leaving millions of low-income Americans without healthcare coverage. To achieve expansion in every state, Congress must renew financial incentives to expand Medicaid by having the federal government fully finance the first three years of expansion as it did for states at the start of the Affordable Care Act.
The Centers for Medicare and Medicaid Services (CMS) has approved dozens of Section 1115 waivers that jeopardize access to care through removal of retroactive coverage, excessive premiums and cost-sharing, tobacco surcharges, lock-outs and other financial and administrative barriers to care. CMS must withdraw State Medicaid Director letters inviting states to apply for work requirements and block grants in their Medicaid programs and deny all current or pending waivers in these areas.
Medicaid is the only major payer that does not provide coverage of routine care for those participating in a clinical trial. This lack of coverage can create a disincentive for participation in trials, which can hinder research, access to promising investigational therapies, and efforts to reduce health disparities. Congress must enact H.R.913, legislation to ensure Medicaid coverage for those participating in a clinical trial who have life-threatening conditions such as lung cancer.
Defend and Expand the Affordable Care Act
Over 20 million Americans gained healthcare coverage as a result of the enactment of the Affordable Care Act, the constitutionality of which is being reviewed by the United States Supreme Court. The Affordable Care Act has made several important changes to the healthcare system that have greatly benefited millions of Americans, including people with or at risk for lung disease.
All patient protections, such as guaranteed issue, community rating, essential health benefits and more, are necessary to prevent discrimination against patients with pre-existing conditions. Congress and the Administration must ensure that these protections are maintained and enforced.
Open enrollment education and outreach programs are essential to enabling individuals to find and select the healthcare coverage that is best for them. Congress must restore funding for outreach and enrollment to previous levels, if not increase funding to allow for as many individuals to access and enroll in the most appropriate coverage as possible.
Guidance released by the Administration in October 2018 regarding Section 1332 waivers enables policies that undermine quality and affordable healthcare. The Administration must rescind this guidance to protect access to care for patients with pre-existing conditions.
In spite of the great strides made by the Affordable Care Act, many Americans still struggle to afford healthcare. Congress and the Administration must enact policies to improve the affordability of care for all, such as by increasing and expanding subsidies for marketplace coverage and by addressing the family glitch.
Enhance Private Coverage
Most Americans have private healthcare insurance, whether sponsored by an employer or purchased independently. It is essential that this care be accessible, affordable, and adequate for all.
Patients who unknowingly see an out-of-network provider, such as during an emergency, should not have to pay any more than if they had been seen by an in-network provider. Congress must put an end to surprise medical bills.
“Skimpy plans” that are not required to adhere to the protections included within the Affordable Care Act pose a grave threat to the health of many Americans. The Administration must repeal the recent rules enabling the proliferation of inadequate insurance, such as short-term, limited-duration and association health plans as well as healthcare sharing ministries, and work with Congress to take additional action to limit the sale and purchase of these plans.
Protect Disadvantaged Communities
Our nation’s healthcare system is riddled with pervasive inequity and systemic bias. Congress and the Administration must take steps, such as those outlined below, to start correcting disparities and improve access to care for disadvantaged communities.
Section 1557 was intended to protect disadvantaged communities, including those living with pre-existing conditions, women, LGBTQI+ individuals, people with disabilities, and those with limited English proficiency, from discrimination when seeking healthcare. In April, 2022, the Lung Association and our partners urged the Biden Administration to repeal the June 2020 final rule regarding Section 1557 of the Affordable Care Act and restore protections against discriminatory practices in the healthcare system.
Individuals should never feel the need to refrain from seeking the care they need because it might negatively impact their or their family members’ immigration prospects. The Administration must repeal the Public Charge rule.
The federal government should enact policies to help those who may be struggling financially to access care, not make it harder. The Administration must withdraw its proposed changes to the calculation of the federal poverty line.
Medicare is available to those who are 65 years of age or older as well as those who have been on Social Security Disability Insurance for a certain amount of time. As with all healthcare coverage, it is critical that Medicare offers quality and affordable care for all those who rely on it, including many with lung disease.
The inappropriate application of measures such as prior authorization can inflict significant harm to patients. Congress and the Administration must ensure that lung disease patients are able to access the treatment they need in Medicare without inappropriate barriers.
Many people on Medicare are attempting to manage complex medical conditions while on a fixed income. Congress must enact policies to increase affordability, such as by restructuring Part D cost-sharing and providing a smoothing mechanism to lower patient out-of-pocket costs and allow patients to pay over time.
Any disease that damages the lungs, including COPD, pulmonary fibrosis (PF) and COVID-19, can lead to a patient needing supplemental oxygen. Under the existing reimbursement and competitive bidding framework, oxygen and the training and service associated with its provision is difficult to obtain, particularly in the case of liquid oxygen. Congress and CMS must enact policies to ensure uninterrupted access to appropriate oxygen modalities for these vulnerable patients.
The United States Preventative Services Task Force (USPSTF) is currently updating its recommendations related to lung cancer screening, and Medicare should update the NCD from 2014 as well. CMS must update and expand coverage for lung cancer screening in line with evidence-based guidelines.
Page last updated: May 23, 2022