One-size-fits-all Medicaid approach wrong for Massachusetts

In the U.S., Medicaid (MassHealth in Massachusetts) covers one in four adults with serious mental illness, so preserving access to all prescription drugs should be a top priority for the program.

Massachusetts — one of 32 states to expand Medicaid under the Affordable Care Act (ACA) — usually is praised for providing healthcare for people living with chronic diseases and other serious health conditions. Unfortunately, the Commonwealth has requested an 1115 Waiver from the Centers for Medicare and Medicaid Services (CMS) that would significantly reduce access to life-saving medications for Medicaid beneficiaries.

{mosads}According to the Kaiser Family Foundation, 1 in 5 Massachusetts residents reported poor mental health in the past year. However, Massachusetts is seeking to establish the first formulary (also known as “preferred drug list” or PDL) for Medicaid in the history of the program. In fact, the state could limit access for patients to only one drug per therapeutic class, leaving Medicaid beneficiaries with very few options for treatment. In addition to restricting patient access to vital medications, this approach could disrupt currently prescribed and effective treatment plans.

Americans living with chronic conditions such as mental illness, arthritis and cancer often rely on a combination of medications or therapies for treatment. Addressing an individual’s needs often requires trying a combination of therapies or medications — sometimes taking years in the case of mental health conditions — to establish a regimen that works specifically for them. Treatment is most effective when doctors have the ability to develop an individual treatment plan. Doing this is contingent on being able to access a variety of options.  

The proposed changes ignore this reality. These changes would instead permit Massachusetts to restrict prescription medications to the Commonwealth’s most vulnerable citizens.

In addition to severely limiting choice, the waiver would also withhold patient access to new and innovative medications. In their request, Massachusetts asserts that drugs coming through the FDA’s accelerated pathway under the 21st Century Cures Act “have not yet proven their efficacy.”

The waiver claims that the University of Massachusetts Medical School, and not the FDA, should be the final arbiter of safety and efficacy of new medications and treatments. This change would be a significant departure from medication safety regulation in the United States and worse, could deny access to innovative

Limiting access to medications by unnecessarily extending the approval process and implementing a restrictive formulary will only exacerbate health care problems in Massachusetts. Multiple studies have found that restricting access to prescription drugs leads to poor adherence, which actually increases Medicaid costs over time.  

In fact, an article from the New England Journal of Medicine states that non-adherence — when people stop taking their prescribed medicines — can result in upwards of $300 billion in avoidable health care costs per year. If Massachusetts is permitted to move forward with the proposed Medicaid restrictions, it will likely perpetuate the issues it is trying to solve.

Massachusetts has always been the health care leader that other states look to for guidance. If approved, the proposed changes in Massachusetts’s waiver could set a dangerous precedent that could spread to other states, harming low-income Americans who depend on Medicaid across the country.  

The American health care community has made important advancements in patient-centered, value-based care. CMS cannot permit Massachusetts’s one-size-fits-all approach to negate that progress. CMS should reject their 1115 Waiver request to protect the citizens of Massachusetts and ensure that low-income beneficiaries who rely on Medicaid continue to receive the care they deserve.

Karen Gromis serves as the Interim Executive Director of the National Alliance on Mental Illness of Massachusetts.