The American College of Surgeons (ACS) Commission on Cancer (CoC) established an Advocacy Committee in 2013, which is responsible for identifying, evaluating, and recommending positions on legislative and/or regulatory issues that come before the state and/or federal government and that have the potential to affect CoC-accredited cancer programs and cancer patients. The ACS CoC Advocacy Committee meets annually to establish a list of priorities and conducts regular conference calls to discuss ongoing developments.
For the last two years, the ACS CoC Advocacy Committee has hosted briefings on Capitol Hill to promote the CoC and the value of accreditation. Furthermore, in February the Advocacy Committee held its first Lobby Day to promote the CoC and discuss cancer research funding, among other issues.
Policy issues related to cancer care often begin in the state legislatures before any federal action is taken. This pattern is especially true for cancer prevention policies, as well as some cancer treatment insurance coverage and access to care issues. In fact, state governments led the way in establishing smoke-free workplaces, raising the legal age to smoke or use tanning beds, regulating e-cigarettes, administering screening and early detection programs, and addressing related health insurance coverage issues. This article focuses on several key cancer issues that state legislatures are addressing this year.
Raising the smoking age
Many cities and a few pioneering states are attempting to raise the legal smoking age to 21 from 18 years old. The movement began in Needham, MA, which in 2005 became the first municipality to increase the minimum age for the purchase of tobacco products to 21. A study showed that after the ordinance’s implementation, the number of Needham youths who smoked declined more sharply than in surrounding communities.1 According to the Centers for Disease Control and Prevention, nearly nine out of 10 cigarette smokers first tried smoking by the time they were 18, and preventing tobacco use among youth is critical to reducing the number of people who become addicted overall.2 Cutting the number of smokers is vital to improving the nation’s public health, as tobacco use is a leading cause of cancer and death from cancer. More than 100 cities have since followed Needham’s example, including New York, NY, which increased its legal smoking age to 21 in 2013.3
Last year Hawaii became the first state to increase its smoking age to 21. The New Jersey legislature passed a bill that called for raising the smoking age to 21 in January of this year, but Gov. Chris Christie (R) pocket vetoed it by taking no action on the legislation. In March, both the California Senate and Assembly had passed a bill (S.B. 7) that would raise the smoking age to 21 and address other tobacco-control related issues. As of press time, it is awaiting action by Gov. Jerry Brown (D). Massachusetts, New York, Oregon, Rhode Island, Utah, Vermont, Washington, and the District of Columbia also considered bills to increase the smoking age to 21 in 2015, but none of them moved to the next stage of the legislative process.4 Pennsylvania, Tennessee, and Utah all have bills active in their 2016 legislative sessions.
A bill also was introduced in the U.S. Senate by Sen. Brian Schatz (D-HI) to raise the legal smoking age to 21 throughout the nation. The Tobacco to 21 Act (S. 2100) prohibits the sale or distribution of tobacco products to individuals under the age of 21. The bill is unlikely to advance in 2016.
Parity for oral chemotherapy
Access to care is another priority issue for the CoC, including improving the availability of new chemotherapies that are administered orally instead of intravenously. Traditional intravenous (IV) anti-cancer medications have been covered health care benefits under most health insurance plans, including Medicare and Medicaid. Cancer patients may only need to make a copayment, or they may incur no cost at all for this treatment. However, many new anti-cancer medications are taken orally, and are covered under a health plan’s pharmacy benefit. These drugs can be expensive, and often health plans require that patients pay coinsurance, which is a percentage of the overall cost of the prescription drug. This payment can be financially burdensome for some cancer patients, and, consequently, many of these patients are unable to fill their prescriptions or complete the entire regimen.5
Legislation was introduced in the states to address this problem by requiring health plans to provide equal coverage for a patient’s out-of-pocket costs for oral and IV therapies. This legislation does not mandate coverage of oral chemotherapy, but it does require health plans to cover treatment equally, meaning patients’ out-of-pocket costs must be the same, regardless of how the therapy is administered. A total of 40 states and the District of Columbia have passed this type of legislation. In 2015, Mississippi, New Hampshire, North Dakota, South Dakota, West Virginia, and Wyoming passed legislation that provides parity for copayments for intravenous and oral chemotherapy. Similar bills are under consideration this year in the following states: Alabama, Alaska, Michigan, North Carolina, Pennsylvania, and Tennessee. The states that have yet to take action are Arkansas, Idaho, Montana, and South Carolina.
Federal legislation that addresses equal coverage for oral and IV therapies also has been introduced. The Cancer Drug Coverage Parity Act would require health insurance plans that cover traditional IV or injectable chemotherapy to provide comparable coverage for orally administered anti-cancer prescription medications. This bipartisan legislation was introduced in the U.S. House of Representatives by Reps. Leonard Lance (R-NJ) and Brian Higgins (D-NY) as H.R. 2739 and in the Senate by Sens. Mark Kirk (R-IL) and Al Franken (D-MN) as S. 1566. The ACS CoC has voiced support for the legislation because it ensures that a patient’s treatment plan is based on the physician’s recommendation, not on the costs associated with an outdated policy.
Tanning bed regulations
In the last few years, states have increased regulations on tanning devices, including banning their use by individuals younger than 18 years old. Use of tanning devices by minors is banned in 13 states: California, Delaware, Hawaii, Illinois, Louisiana, Minnesota, Nevada, New Hampshire, North Carolina, Oregon, Texas, Vermont, and Washington. In addition, 42 states regulate the use of tanning devices in some manner. In 2016, the College will work with a coalition in Kansas to advance legislation (H.B. 2369) that would ban the use of tanning beds by individuals under the age of 18.
Although at present no federal legislation bans the use of tanning devices by minors, the U.S. Food and Drug Administration did propose a rule on December 22, 2015, that would restrict the use of these devices to individuals 18 years of age and older.
Colorectal cancer screening coverage
The Affordable Care Act mandates coverage of colorectal cancer screenings, including colonoscopies, sigmoidoscopies, and fecal occult blood testing, without any cost sharing. The extent of this coverage isn’t always clear and has created confusion in a number of instances. For example, if someone gets a positive result on a fecal occult blood test, a follow-up colonoscopy is required. However, it may be unclear whether the colonoscopy is covered as part of the original screening, or is considered a separate diagnostic test.
In the last year, at least six state legislatures have considered legislation attempting to clarify this distinction and address other gaps in colorectal cancer screening. For example, an Oregon bill (H.B. 2560) was signed into law in 2015, which requires health care insurers to cover the cost of a colonoscopy for individuals who are 50 years of age or older and have had a positive fecal test result. The law also requires health benefit plans to cover the cost of a colonoscopy for individuals ages 50 and older and who have a positive fecal immunochemical test result. Other state legislatures that are considering bills aimed at increasing colorectal cancer screenings include Florida, Hawaii, Kentucky, Massachusetts, and New York.
Activity related to colorectal cancer screening also is taking place at the federal level. When the Affordable Care Act was first passed, there was confusion regarding polyp detection and removal during a colonoscopy screening and whether it was part of the screening test or a separate therapeutic procedure. Some health care insurers treated it as the latter and sent bills to patients for some or all of the procedure’s costs. In 2013, the Obama Administration clarified that polyp removal is part of the screening process and should be covered without cost sharing. However, this directive did not address Medicare coverage. The Removing Barriers to Colorectal Cancer Screening Act (H.R. 1220/S. 624) would address this gap. The ACS CoC has previously supported this legislation to ensure that Medicare beneficiaries have access to the full benefits of colonoscopies without bearing responsibility for cost sharing.
Promoting CoC accreditation
One important goal of the ACS CoC Advocacy Committee is to promote CoC accreditation at both the state and federal levels. Florida Gov. Rick Scott (R) in 2013 approved legislation creating the Cancer Center of Excellence Award to recognize hospitals, treatment centers, and other providers in the state that demonstrate excellence in offering patient-centered, coordinated care to patients receiving cancer treatment and therapy. To be considered for the award, the provider must have CoC accreditation. The state Surgeon General appoints a team of independent evaluators to determine award eligibility. Last year, four cancer centers were the first to earn the Cancer Centers of Excellence designation. This award is an example of how a state can promote CoC accreditation.
At the federal level, in late 2015, Reps. Lynn Jenkins (R-KS) and Richard Neal (D-MA) sponsored H.R. 487, a nonbinding resolution that recognizes the importance of CoC accreditation to ensure patient access to high-quality, comprehensive cancer care. Visit SurgeonsVoice to learn more about this resolution and to ask your representative to sign on.
If you are interested in getting more involved in advocating for the CoC in your state, contact your CoC State Chair (information available online). To learn more about getting involved in state advocacy, contact ACS State Affairs staff at firstname.lastname@example.org. To learn more about the ACS CoC Advocacy Committee, contact Nina Miller, MSSW OSW-C, Cancer Initiatives Manager, at email@example.com.
- Schneider S, Buka S, Dash K, Winickoff J, O’Donnell L. Community reductions in youth smoking after raising the minimum tobacco sales age to 21. Tob Control. June 12, 2015. Available at: http://tobaccocontrol.bmj.com/content/early/2015/06/12/tobaccocontrol-2014-052207.1.full?sid=0a9ab93c-0331-400c-9496-8cac540c6e68. Accessed January 26, 2016.
- U.S. Centers for Disease Control and Prevention. Smoking and tobacco use. 2012 Surgeon General’s Report—Preventing Tobacco Use Among Youth and Young Adults. Available at: www.cdc.gov/tobacco/data_statistics/sgr/2012/index.htm. Accessed February 24, 2016.
- States and localities that have raised the minimum legal sale age for tobacco products to 21. Campaign for Tobacco-Free Kids. Available at: www.tobaccofreekids.org/content/what_we_do/state_local_issues/sales_21/states_localities_MLSA_21.pdf. Accessed January 26, 2016.
- Preventing Tobacco Addiction Foundation. Latest Tobacco 21 state developments. Available at: http://tobacco21.org/breaking-news/. Accessed January 26, 2016.
- Streeter SB, Schwartzberg L, Husain N, Johnsrud M. Patient and plan characteristics affecting abandonment of oral oncolytic prescriptions. J Oncol Pract. 2011;7(3 suppl):46s-51s. Available at: http://jop.ascopubs.org/content/7/3S/46s.full. Accessed January 25, 2016.