Study: Missouri's anti-cancer laws insufficient

A new report has shown Missouri is one of the three worst states in the country for passing meaningful legislation to prevent cancer-related suffering and death.

The study is called "How Do You Measure Up?" and is published by the American Cancer Society (ACS) Cancer Action Network. The study has been conducted annually for 12 years and is a progress report on state legislative activity to reduce cancer incidences/mortalities.

"We have the tools to reduce cancer diagnoses and deaths across the country," said Stacy Reliford, Missouri's government relations director for ACS, in a press release. "Missed opportunities to pass laws fighting and preventing cancer not only limit the potential for increased state revenues and health savings, but also limit the possibilities for saving countless lives from a disease that will kill an estimated 12,870 Missourians this year."

The study focuses on three subjects: tobacco, prevention and access to care.

Within these subjects there are multiple subcategories. For tobacco, there are cigarette tax rates, tobacco tax rate increases over time, smoke-free laws, Medicaid coverage of tobacco cessation and tobacco prevention program funding. Prevention was judged on physical education and time requirements for school children, indoor tanning device restrictions for minors, and breast and cervical cancer early detection programs. Access to care was graded on increased access to Medicaid, policies to prevent and treat pain, access to palliative care, and restrictions on tobacco rating.

Palliative care is when doctors just try to control the symptoms, or rather when doctors try to improve the conditions instead of prolonging the life of the patient, said Dr. John Bechtel, a Jefferson City Medical Group oncologist who is affiliated with St. Mary's Health Center.

Missouri failed, or was falling short, in every category except for Medicaid coverage of tobacco cessation, the pain policies and access to palliative care, according to the report. However, the majority of the states are not meeting the benchmark either. Only Massachusetts got a passing grade by meeting standards in nine or more of the categories. Although the other states did not do well, Missouri fared particularly poorly, as it is tied for last with Tennessee and Mississippi.

The report is "not really so much about the practice of medicine," Bechtel said. "It is more about government funding cancer screening, and are there laws preventing people from being exposed to secondhand smoke and such. And that is where Missouri did not fare too well."

Tobacco

Missouri appears to be the most friendly state to tobacco users and companies, Bechtel said. At least five bills and one resolution that restrict or change tobacco use and revenue died in the Legislature this year. All the bills were sponsored by House Republicans, the majority party, but never made it to the Senate.

Missouri also has the nation's lowest excise tax rate for cigarettes at $0.17 per pack, while all surrounding states have more than double that tax. The state with the rate closest to Missouri's is Virginia with $0.30, according to the report. The last time Missouri raised the tax was 1998, Reliford said. For these reasons, Missouri was classified as falling short in cigarette tax rates and price increases over time.

"There are some pretty clear studies that show if tobacco is more expensive, then there are fewer people who pick up smoking," Bechtel said. "It's been voted on, and we voted it down. ... The government has to reflect the will of the people, and it did there. As a doctor, sure I wish that law would have passed and the cigarette tax would have went up. But what can you do?"

Missourians voted against a ballot issue authorizing higher tobacco taxes to fund smoking cessation/prevention and treatment in 2012. The price raise of $0.0365 per cigarette would have raised as much as an estimated $420 million for the funding of cessation and prevention programs for elementary, secondary schools as well as colleges and universities.

Missouri's cities, including Jefferson City and Columbia, have taken steps toward smoke-free public areas, but the report faulted Missouri for not having similar statewide legislation.

Although that type of legislation often deals with issues of personal freedoms, Bechtel said evidence shows secondhand smoke leads to an increased risk for lung cancer. "But from a pure health standpoint, we (doctors) would love for no one to ever be exposed to smoking," he said.

State tobacco prevention programs received less than $77,000 for fiscal year 2014, according to the report. The Center for Disease Control (CDC) has recommended the state spend at least $72 million for prevention and cessation programs for the state's estimated number of tobacco users, meaning Missouri uses 0.1 percent of the recommended funds.

But more realistically it will be 0 percent with zero dollars used for programs since more than $300,000 was withheld from this year's budget for new programs, Reliford said.

The only area in tobacco where Missouri did better than failing, but still not well, was in Medicaid coverage of tobacco-cessation programs. Missouri Medicaid offers counseling to help quit smoking, and six of the seven Food and Drug Administration-approved prescriptions for quitting. If the state covered all seven drugs and all forms of counseling, it would graduate from "some progress" to "doing well" in the report.

Prevention

Children in Missouri public schools are offered the proper amount of time to play, but they aren't provided enough health-related education, so the state has failed this category as well.

"It is more about the health instruction," Reliford said. "Our data shows that quality physical education is the best way for kids to get the recommended physical activity because it allows them to obtain the knowledge and skills they need to be physically active throughout their lifetime."

The state passed legislation restricting the use of tanning beds by minors, but it is the same failing category as states without legislation because it allows minors to use the device with written consent from a parent. To get to the "some progress" grade, the state must require a parent to accompany the child with every visit and to get to "doing well" legislators must prohibit minors' use of tanning beds.

Skin cancer is the most commonly diagnosed cancer in the United States, according to ACS cancer figures from 2014. They state that an estimated 13,000 men and women will die from skin cancer this year, and 9,710 of those deaths will be from melanoma. Exposure to sunlight and indoor tanning devices is the most avoidable risk factor for this cancer.

Missouri has funded breast and cervical cancer detection programs with approximately $500,000 every year for at least the past five years, Reliford said. But this is only 18 percent of what the CDC recommends. The state funds are matched by federal funds and the ACS is pushing for more federal and state money, she said.

The Missouri program called "Show Me Healthy Women" provides screenings to women that meet the age, income and insurance guidelines at around 189 facilities, according to the Department of Health and Senior Services web page. For the last five years, this program has detected more than 500 cases of breast cancer and 450 cases of cervical cancer, and any woman with a detected abnormality can receive free treatment and diagnostic services through the program's providers.

Even with such a successful program, Missouri still failed in the category for early detection.

Access to care

Missouri failed to increase access to Medicaid because the state officials chose not to opt into the recent Medicaid expansion. The state failed in the restrictions to tobacco ratings category because the Affordable Care Act allows insurance companies in Missouri to charge 50 percent higher premiums to smokers.

"We believe that making insurance coverage more expensive goes against the intent of the law," Reliford said. "There is little evidence that these types of financial penalties have a positive effect, and it makes premiums unaffordable to patients who need it most."

Research shows people without health insurance are more likely to be diagnosed with cancer later in life, and are more likely to die from the disease, according to the report.

Missouri is making some progress with its access to palliative care and its pain policy.

ACS officials are pushing for more education on palliative care and to set up a panel of physicians and patient advocates that could help draft better legislation to address palliative care needs, Reliford said.

The society is also pushing for changes in the Intractable Pain Treatment Act. For example, the definitions of dependency and addiction within the act are the same, but the society officials believe dependence and addiction are very different. This and the other planned changes will improve the access to pain treatments for those in need, Reliford said.

Tobacco lobbyists didn't respond to interview requests. Officials from the Department of Health Senior Services and for the Senate's Ways and Means and Fiscal Oversight Committee refused to comment on the record. A spokesman for the Division of Alcohol and Tobacco Control's stated its only role with tobacco involves enforcing laws related to youth tobacco sales, and the division had no role with the issues of this story.