In setting health care reform’s path, we must protect equity in care

This year is shaping up to be another year of monumental changes for health care in this country. With the two -year anniversary of the Affordable Care Act (ACA) bill signing fast approaching, stakeholders across the country are working feverishly to build the infrastructure and get the necessary provisions in place so that the goals of the ACA can be attained. Even with the looming Supreme Court decision muddling the process, there are steps that the Centers for Medicare and Medicaid Services (CMS) can take now to solidify some of the key patient protections that have stood at the center of health reform over the last few years.

One of the most promising aspects of the ACA, from the kidney patient community’s perspective, is its creation of a baseline Essential Health Benefits (EHB) package that will create a floor of benefits and services offered by all insurance plans as of 2014. This key provision was created with the intent to ensure a consistent, minimum level of benefits across all plans, to allow easier comparisons of plans for consumers and to prevent insurers from manipulating health plans to “cherry pick” healthier enrollees.

This new benefits package and the creation of the new state-based health insurance exchanges hold great potential in expanding access to care; providing choice in coverage; assisting with the cost of coverage; and prohibiting plans from eliminating coverage because of an individual’s health status.

For kidney patients across the country, both the benefits package and state-based exchanges hold great promise for expanding access and increasing the quality of care they receive. As kidney patient representatives, it is our goal to ensure that kidney patients are able to take advantage of these new patient protections and the new simplified marketplace that the exchanges aim to create. However, due to a possible oversight, there remains confusion as to whether ESRD patients will have the ability to access insurance through the new exchanges. We are calling on CMS to take action now to clarify and protect insurance offerings for the nation’s vulnerable kidney patients.

Individuals living with end stage renal disease (ESRD), also known as kidney failure, must receive either life-sustaining dialysis treatments— typically, several times a week for 3-4 hours per session— or a kidney transplant to survive. On top of this, ESRD patients often have multiple health issues that can complicate their care. ESRD is an incurable disease. Due to patients’ dependence on life-long care, and the fact that their treatment may prevent them from working and qualifying for workplace health insurance, in 1972, Congress extended Medicare coverage to all ESRD patients, regardless of age.

In a fair and compassionate action designed to help ESRD patients more smoothly transition to Medicare coverage, CMS allows patients who have private health insurance when diagnosed with ESRD to keep their coverage for the first 30 months following diagnosis. After those 30 months, Medicare takes over as the primary payer. This policy, known as Medicare Secondary Payer (MSP), gives patients the opportunity to learn more about their condition; take advantage of their current plan’s care offerings— which are often more robust than the Medicare benefit; make necessary coverage changes for dependent family members; and determine how Medicare will handle their coverage moving forward.

MSP has been a popular and highly valued benefit for ESRD patients with private coverage. At a time of uncertainty and upheaval following the diagnosis of a chronic disease, MSP allows patients and their families to remain on the same insurance for a longer period of time, and can limit patients’ out-of-pocket costs as they see their medical bills begin to climb.

Unfortunately, although the ACA requires that the new exchange benefit not be designed “in ways that discriminate against individuals because of their age, disability, or expected length of life,” it does not specify whether MSP will apply to patients covered by the exchanges who develop kidney failure. We urge CMS to make certain its implementation does not discriminate against individuals with ESRD, by ensuring these patients are able to retain private insurance coverage in the exchanges the same way they have been able to in their employee group plans.

In response to a Congressional inquiry, Health and Human Services (HHS) Secretary Kathleen Sebelius has indicated that MSP policy would apply in the exchanges, saying that the ACA “does not change existing Medicare secondary payer rules should ESRD beneficiaries become enrolled in a qualified health plan through an exchange.” It is now up to CMS to make sure that these intentions become binding under the terms of the law.  We request CMS take immediate action to solidify the Secretary’s interpretation through formal guidance.

In representing the approximately 500,000 Americans with ESRD, and the tens of millions more living with chronic kidney disease, we have strongly supported the patient-centered goals of health reform. Now, nearly two years after its passage, the reform law’s patient protections are within sight— if our policymakers will work together to carry it through properly. Providing fair and equal treatment for all citizens is our greatest responsibility to now uphold, and ESRD patients are counting on us to get it right. 

The American Association of Kidney Patients, American Kidney Fund, Dialysis Patient Citizens, National Kidney Foundation, Renal Support Network advocate strongly on behald of ESRD patients who rely on life-saving dialysis treatments to fight kidney failure.

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