Health Care Reform and Access to Hematopoietic Cell Transplantation

The landmark health care reform bill, the Affordable Care Act (ACA), was implemented on January 1, 2014. Among the changes to the United State's health care system are three main aspects: 1) creation of health insurance exchanges, 2) definition of essential health benefits and 3) Medicaid program expansion. The health insurance exchanges will act as marketplaces for people to shop for and compare health insurance plans in their state. There are three models of health insurance exchanges: federally facilitated, state run and partnership exchanges that have input from both the state and federal governments. Each state chose to create their own exchange or to have the federal government create and operate their state exchange. The exchanges present an opportunity for people to access affordable health insurance through federal tax credits that will subsidize premiums for individuals and families up to 400 percent of the federal poverty level (FPL). The exchanges are expected to enroll 7 million people in the first year of the ACA. Each exchange will offer a variety of qualified health plans (QHP) that are approved by the state and/or the US Department of Health and Human Services (HHS). Every QHP and non-grandfathered commercial health insurance plan is mandated to include a minimum level of coverage known as an essential health benefit (EHB) package selected by each state. Information was collected on each state's EHB plan to determine coverage of hematopoietic cell transplantation (HCT), and was analyzed for the level of HCT benefits with consideration of the Recommended Benefit Design For HCT developed by the National Marrow Donor Program (NMDP) (www.payor.bethematchclinical.org). States were then divided into three categories: poor coverage, fair coverage and excellent coverage. Eleven states had poor coverage, 12 states had fair coverage and 28 states had excellent coverage included in their EHBs. While access to health insurance is expanding, it is important that coverage of HCT meets levels prescribed in the Recommended Benefit Design For HCT. Additionally, states were able to expand their state Medicaid programs to include adults up to 138 percent of the FPL. To date, twenty-five states are expanding their Medicaid programs, resulting in increased access for low-income adults in their states. In states that expanded their Medicaid programs, 31,587,000 adults are now eligible to access to health insurance coverage through Medicaid (Kaiser Family Foundation). A study done by the NMDP provides HCT incidence rates that translates to a possible 2,148 Medicaid patients needing an allogeneic HCT following Medicaid expansion by states that have already voted to expand in the first year of ACA implementation.  Transplant centers will need to understand how their state operates in each of these three aspects in order to provide patients with access to HCT in 2014 and beyond.