Health Plans Can’t Dodge Paying for Expensive New Cancer Treatments, Says Michigan’s Top Insurance Regulator

January 15, 2024, 9:33 PM

After ProPublica reported on a health insurer that refused to cover the only medicine that could save a cancer patient’s life, Michigan insurance regulators clarified that, by law, many plans must pay for any clinically proven treatments. 

This story first appeared in ProPublica on Jan. 9 and was done in partnership with Scripps News.

By Robin Fields and Maya Miller

Forrest VanPatten died in 2020. (Obit photo)

In a victory for many cancer patients in Michigan, the state’s top insurance regulator told health plans on Monday that they cannot deny coverage for clinically proven cancer treatments, and she made it clear for the first time that this includes cutting-edge genetic and biologic therapies.

The move follows weeks of questions from ProPublica and pressure from state lawmakers after the news organization reported in November that an insurer there refused to pay for the only treatment that could save the life of Forrest VanPatten, a 50-year-old father of two, even though a state law requires insurers to pay for proven cancer drugs.

Internal emails obtained by ProPublica showed that executives at Priority Health, the second-largest insurer in Michigan, had argued that the expensive treatment VanPatten needed was a gene therapy, not a drug, so the state’s mandate didn’t apply. VanPatten died in February 2020, still fighting for access to treatment. Priority Health’s associate chief medical officer had tried fruitlessly to convince his bosses that the company was required to cover the treatment, known as CAR T-cell therapy. He later told ProPublica: “We crossed the line.”

Forrest VanPatten’s widow, Betty, and their two adult children said they hoped the historic directive from Michigan’s insurance regulator would ensure that other families wouldn’t have to go through what theirs did.

More than 30 years ago, state legislators passed the law because they were fed up with insurers finding excuses to get out of covering treatments for cancer patients. Now, the Department of Insurance and Financial Services’ bulletin to insurers makes it clear that therapies that have been developed using technologies that didn’t exist when the law was originally written must be covered. The agency previously acknowledged to ProPublica that it hadn’t taken any actions to enforce the law since it was enacted in 1989.

In the press release announcing the step, the department’s director, Anita Fox, said her department was “committed to protecting Michiganders by ensuring that health insurers are following all state and federal laws and regulations.”

A Priority Health spokesperson said the company hadn’t yet seen the bulletin and couldn’t comment on it. In a written response to ProPublica questions on lawmakers’ outrage over the VanPatten case, the spokesperson wrote: “We welcome the opportunity to answer any questions from legislators about coverage decisions." He said the company had begun covering CAR T-cell therapy “several years ago” — after VanPatten died — based on clinical improvements. He added that Priority Health follows all state and federal coverage requirements and wrote: “The health and safety of our members is always our top priority.”

In earlier comments to ProPublica, Priority Health had said there was initially a lack of consensus in the medical community around the treatment VanPatten needed. But well before VanPatten’s doctors requested Priority Health’s approval for the medication, there was substantial consensus about the efficacy of the treatment, according to the National Comprehensive Cancer Network, an alliance of leading U.S. cancer treatment centers.

Not all Michigan health plans have to follow the state law. Some employers pay directly for the health care of their workers and hire insurers only to process claims. These plans are regulated by the federal government and are exempt from state coverage requirements, though some follow them voluntarily.

Michigan’s legislative session is set to open on Wednesday, and several members have been pushing the state insurance department to investigate Priority Health’s actions in the VanPatten case, calling out insurance regulators for failing to enforce the statute.

Laura Hall, communications director for the state insurance department, said she couldn’t reveal whether the agency was investigating Priority Health unless a formal enforcement action is taken.

Even after the insurance department’s bulletin to health plans, Sen. Jeff Irwin, a Democrat from Ann Arbor, said he still supports writing a new bill to make it “painstakingly clear” that the new generation of cancer treatments are covered under Michigan law. He called Priority Health’s actions “unconscionable” and said in a written statement that he wants an investigation into “why and how this family was subjected to denial, delay, and death.”

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