Medicare Immunosuppressive Drug Coverage Bills

Can We Afford Them?

Vanessa Grubbs

Disclosures

American Journal of Transplantation. 2019;19(7):1877-1878. 

When 33 years old, Robert Phillips went to his transplant evaluation appointment in 2004 and he was told he was nearing the top of the waitlist. He had been on dialysis for 5 years but was 32 years away from being eligible for Medicare's lifetime immunosuppressant coverage after transplantation. He recalls the financial counselor saying, "Even after your insurance pays, you will still have to pay $215 every month for the medications. Can you afford that?"[1]

In this issue of American Journal of Transplantation, Hart and colleagues[2] suggest that the answer to this question for many kidney transplant recipients is "no." Because Medicare is the primary health care insurance for more than half of kidney transplant recipients, the findings of this study warrant attention. Although prior studies have examined the contribution of Medicare's 1- and 3-year time limitations on immunosuppressant coverage to observed worse outcomes compared to recipients with private insurance, the authors demonstrate that these time limitations do not tell the complete story by examining outcomes based on when eligible Medicare beneficiaries lose their coverage.[3]

Among Medicare-covered kidney transplant recipients younger than the age of 65 years, they found that those who lost their Medicare early (<3 years) and late (>3 years) were associated with lower medication adherence and in the teens-fold higher risk of graft loss compared to recipients who lost their Medicare "on time" (at 3 years). The risk of early Medicare loss was nearly 40% higher for blacks compared to whites. In addition, Hart et al found that both early Medicare loss and graft failure rates were higher among those living in lower income neighborhoods. Although the authors acknowledged that they were unable to explore the specific reasons for early or late Medicare loss, the assertion that recipients' inability to pay Medicare premium or medication copays is likely, as they can total upwards of $400 month for the average kidney transplant recipient.[4]

For nearly the past decade, a bill to eliminate time limitations on Medicare eligibility for immunosuppressants for kidney transplant recipients has been introduced in every session—and failed. Each bill proposed to amend Medicare policy to extend immunosuppressive drug coverage beyond 3 years for kidney transplant patients who would not otherwise qualify for Medicare benefits by age ≥65 years and/or disability. Transplant advocacy groups argued eloquently that "removal of the arbitrary time limit on immunosuppressive drug coverage makes financial sense, but more importantly the unnecessary human toll as a result of the current policy is tragic and unconscionable…."[5] H.R. 2969/S.1454 from 112th Congress (2011-2012) was the most successful with nearly 150 bipartisan sponsors, but like its predecessors, it did not make it out of Committee and the Congressional Budget Office has never calculated the cost of the program. Most recently, H.R. 6139/S. 3487 of the 114th Congress (2015-2016) had just 20 cosponsors, with none in the Senate. That no bill gained significant traction toward amending law is particularly disturbing when one considers that the authors' findings suggest that these bills do not go far enough for many kidney transplant recipients.

As Medicare faces insolvency in 2024 and pays nearly three times more for dialysis than transplantation, one would think that potential solutions that are more cost-effective would resonate with Congress. Instead, given that the life expectancy of dialysis is less than half that of transplantation (Figure 1), it appears that Congress is banking on the fact that dead patients are less expensive than living ones.

Figure 1.

Expected life expectancy, males. Data Source: United States Renal Data System.7

Perhaps it would help to recall that the Medicare end-stage renal disease (ESRD) entitlement was not initially ratified because of an economic rationale. Rather, it was because patients considered most deserving of the lifesaving but expensive treatment began dying due to inability to pay as exemplified by testimony from Shep Glazer, a dialysis patient from New York:

" I am 43 years old, married for 20 years, with two children ages 14 and 10. I was a salesman until a couple of months ago until it became necessary for me to supplement my income to pay for the dialysis supplies…. Gentlemen, what should I do? End it all and die? Sell my house for which I worked so hard, and go on welfare? Please tell me. If your kidneys failed tomorrow, wouldn't you want the opportunity to live? Wouldn't you want to see your children grow up? (U.S. Congress, House, Committee on Ways and Means, 1971b) [6]"

Hart et al provide evidence of a similar reality for kidney transplant recipients under current law. Many kidney transplant recipients are dying far sooner than expected because they cannot afford to pay to keep their Medicare coverage and, therefore, their grafts alive. So instead of the transplant community continuing to present the same case that we have to Congress for the past decade, perhaps with the next proposed bill we should start asking, "Who has to start dying in order to implement change that saves lives?" Our patients' lives cannot afford the status quo.

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