The problematic rollout of the Affordable Care Act’s website, HealthCare.gov, made good political theater, but while much of the heated discussion centered on the plan’s need to enroll “young invincibles,” America’s cancer care system and the older patients it serves were also affected by parts of the bill implemented in January 2014. Notably, insurance companies can no longer deny coverage for preexisting conditions, such as cancer, or put lifetime dollar limits on policies, once a financial trapdoor for cancer patients.
Beyond these valuable new provisions, one of the aims of the Affordable Care Act is to incrementally move the country toward universal health-care coverage. The scope is formidable: Prior to implementation of the Affordable Care Act, more than 47 million Americans—about 18% of the population—were uninsured. To begin the process, two major provisions went into effect this year: the creation of health insurance marketplaces, where low and moderate income families receive premium tax credits for coverage, and expanded Medicaid coverage to all individuals not eligible for Medicare under age 65 with incomes up to 138% of the federal poverty level (although, at this time, 24 states have chosen not to move forward with the Medicaid expansion).
In a Journal of Clinical Oncology article published the year after the Affordable Care Act was signed into law, the authors wrote, “The elimination of cancer disparities is critically important for lessening the burden of cancer. The [Affordable Care Act] provides both the opportunities and challenges for addressing cancer care disparity and access to care.”1
The ASCO Post asked the article’s lead author, Beverly Moy, MD, MPH, Clinical Director of the Breast Oncology Program at Massachusetts General Hospital, Boston, to comment on the effects of the Affordable Care Act’s 2014 rollout. “I would say that the [Affordable Care Act] has had less effect in Massachusetts compared with other areas of the country since we have had health-care reform since 2006. A recent study published in the Annals of Internal Medicine showed that death rates in Massachusetts are lower compared with comparable areas of the country since near-universal health-care coverage began in 2006.2 Improvements in mortality were greatest in counties where incomes were lower and pre-reform uninsured rates were higher,” said Dr. Moy.
Dr. Moy remarked that while the benefits seen in the study may not be generalizable to other states, these data suggest that improving access to health care leads to better clinical outcomes. “Moving beyond demanding access to health insurance for all Americans, we should also carefully scrutinize the medical benefits offered under Medicaid in order to ensure the best cancer care possible,” said Dr. Moy.
Expanding Medicaid
On June 28, 2012, the Supreme Court issued a ruling upholding the constitutionality of the Affordable Care Act; however, the high court also ruled that individual states have the right to choose whether to adopt the Act’s Medicaid expansion, which some governors have opted out of, claiming that it would place an undue financial burden on their states. More than 15 million uninsured adults could become newly eligible for Medicaid across all states.
The sheer number of potential enrollees makes for gargantuan challenges, but for populations of uninsured, low-income people with cancer, the Medicaid expansion program offers an opportunity for new access to cancer care. Nevertheless, studies have found disparities in outcomes among Medicaid cancer patients and inadequacies in the program’s process of care.3 Some experts have even posited that uninsured cancer patients fair no worse than their counterparts enrolled in Medicaid.
According to health policy expert, Siran M. Koroukian, PhD, Associate Professor in the Department of Epidemiology and Biostatistics at Case Western Reserve University, Cleveland, most studies that compare cancer outcomes between Medicaid patients and the uninsured rely on data that reflect insurance status at a given point in time, such as time of diagnosis, without accounting for the patient’s history of enrollment in relation to the diagnosis of cancer.
“The Medicaid population is heterogeneous, consisting of long-time enrollees and those who join the program as a safety net after being diagnosed with a life-threatening disease, such as cancer. For various reasons, the safety-net group, comprised mostly of individuals who may have been previously uninsured or underinsured, is more likely to have worse cancer outcomes than long-time Medicaid enrollees. These findings demonstrate the benefit of being on Medicaid rather than uninsured, relative to cancer outcomes,” said Dr. Koroukian.
When States Opt Out
The Congressional Budget Office estimates that the federal government will bear nearly 93% of the costs of the Medicaid expansion over its first 9 years, from 2014 to 2022. The federal government will also pick up 100% of the cost of covering people made newly eligible for Medicaid from 2014 to 2017 and no less than 90% on a permanent basis. Currently, 27 states, including the District of Columbia, are implementing Medicaid expansion; 5 states are in open debate about the issue, and 19 states are not moving forward with Medicaid expansion.
To shed light on the issues facing states that decline the Affordable Care Act’s offer of Medicaid expansion, The ASCO Post spoke with Martin J. Heslin, MD, MSHA, Chief of Surgical Oncology and Associate Director for Clinical Programs at the University of Alabama at Birmingham (UAB) Comprehensive Cancer Center. Dr. Heslin said that Medicaid has been an issue in Alabama for a long time due to four issues: (1) Alabama is the only state where the hospital portion of the State Medicaid portion is funded 100% by the hospitals themselves, (2) Medicaid only reimburses 67% of costs, (3) the disproportionate share payments, which compensate hospitals that treat low-income patients, will be significantly reduced, and (4) Medicaid is moving to a managed care program, and cost savings will only be through improved population health management.
To deal with their impending fiscal travails, UAB and a number of statewide stakeholders are working to form a Regional Care Organization whose goal is to manage the risks of a Medicaid population. “This is obviously a large shift from a volume- to a value-based care program. Currently we provide state-of-the-art cancer care regardless of the patient’s ability to pay, even though we lose money through our current Medicaid program,” said Dr. Heslin.
The other critical issue in Alabama is the Affordable Care Act’s high-deductible plans. Data suggest that Alabama residents have lower-than-national-average monthly premiums, but one of the highest average deductibles in the nation.
“The concern is that patients might not seek care in a timely fashion or that they might be financially compromised with a very high deductible for lifesaving cancer care. Similarly, some families might not be able to pay very high deductibles, which will increase the institution’s bad debt. Like other institutions, UAB has revised its charity program to manage families that cannot pay the large deductible. Ultimately, the goal at UAB is to provide quality cost-effective care regardless of one’s payer status,” said Dr. Heslin.
Inner-City Cancer Patients
John V. Cox, DO, MBA, FASCO, is part of a 10-doctor team at Texas Oncology Methodist Dallas Cancer Center, that serves a safety-net hospital in urban Dallas. Asked about access issues under the Affordable Care Act, Dr. Cox responded, “We recognize it is early and we are monitoring multiple issues, but as of now I’m not aware of any identifiable access problems. The issue we’re most concerned about is the [Affordable Care Act’s] 90-day grace period rule for patients on premium payments, which puts us at risk for providing expensive services we might not be reimbursed for. The [Affordable Care Act] exchange plans in our area are providing real-time data on the payment status of the patients we care for. To my knowledge, that system is working adequately.”
Dr. Cox’s patient population is largely blue-collar working poor with difficult financial challenges. “When you have a malignancy, you’re going to use up the [Affordable Care Act’s] $6,300 deductible pretty quickly, which can create a barrier to the working poor. We have certain payment plans to offer, but given the expensive therapies we deliver, I fear the high deductible is going to create access problems down the line.”
On a positive note, Dr. Cox believes that all the political ballyhoo over the health insurance exchanges has informed and encouraged many Medicaid-eligible Texans to visit HealthCare.gov and evaluate their own coverage opportunities. “Texas has very stringent Medicaid guidelines, but we’re seeing an uptick in enrollment and we’re hopeful that it will make a significant dent in the uninsured in our state,” said Dr. Cox.
Asked about Medicaid’s historically low reimbursement rates to providers, Dr. Cox observed, “The real tension in our practice is seeing patients who fall between the cracks of Medicare’s reimbursement guidelines. We fight to provide quality care for uninsured patients, and oftentimes we lose money in the process. Texas is among the states with the poorest Medicaid reimbursement rates in the country. We’re certainly not looking to become a primary Medicare provider, but hands down it is better than treating cancer patients who are uninsured. Dealing with the uninsured drains a huge amount of our time and resources.”
Dr. Cox acknowledged that Medicaid creates barriers to care. “Medicaid poses access issues because a lot of our specialty colleagues in the area don’t accept patients from the program. But Medicaid is far better than being uninsured,” said Dr. Cox, adding, “There are multiple provisions in the [Affordable Care Act] that serve our cancer patient populations. Speaking as a doctor who treats a lot of working poor patients, anything that gets them health coverage is good.”
Cancer Prevention
According to Johnie Rose, MD, PhD, Assistant Professor and Preventive Medicine Residency Program Director at Case Western Reserve University, a significant benefit of the Affordable Care Act is improved access to numerous evidence-based preventive services.
“Under the [Affordable Care Act], most insured individuals will receive first-dollar coverage of U.S. Preventive Services Task Force–recommended clinical preventive services including screening and intervention for obesity, tobacco use, and alcohol abuse and screening for colorectal cancer, breast cancer, cervical cancer, and—most recently—lung cancer. Importantly, with 26 million Americans expected to gain insurance as a result of [the Affordable Care Act] by 2017, more people will be in a position to access these newly covered services,” said Dr. Rose.
He continued, “The [Affordable Care Act] also takes some steps to reduce risk factors for many cancers through enhanced support of workplace wellness programs, grants for various wellness demonstration projects, grants for community health programs, and requirements for nutritional labeling of menu items at chain restaurants.”
Top Cancer Centers
There is substantial pressure under the Affordable Care Act for exchange plans to limit the growth of health costs. Recently, several articles in the lay press have pointed out that many of the nation’s leading academic cancer centers are not included in certain plans covered by the Affordable Care Act’s insurance exchanges. Some experts are concerned that cost-reduction provisions in the law might compromise access to premier cancer centers. In reaction, the Obama administration has released a statement saying that insurers in states served by federal health exchanges will receive closer scrutiny to ensure compliance with the law.
According to Michael N. Neuss, MD, Chief Medical Officer, Vanderbilt-Ingram Cancer Center, Nashville, “I have never been aware of a patient who needed treatment who was denied that care for payment reasons. Hospitals and pharmaceutical companies have been excellent and generous partners to physicians who have donated their expertise, effort, and time for patients who were unable to pay. This collaborative tradition is as old as our profession.”
Dr. Neuss noted that in a few instances, established patients have purchased Affordable Care Act plans that were not included in Vanderbilt and the Vanderbilt-Ingram Cancer Center coverage. “Several patients have had to change providers who are outside of our system. Unfortunately, two patients had to stop participation in clinical trials because they weren’t open in the facilities participating in their plan,” said Dr. Neuss.
He continued, “For all the business language of panels, coverage plans, open enrollment periods, and preexisting conditions, the bottom line is clear: Patients want to be insured. The Affordable Care Act provides a pathway to health-care coverage, and we’re in a better place because of it.” ■
References
1. Moy B, Polite BN, Halpern MT, et al: American Society of Clinical Oncology policy statement: Opportunities in the patient protection and affordable care act to reduce cancer care disparities. J Clin Oncol 29:3816-3824, 2011.
2. Sommers BD, Long SK, Baicker A, et al: Changes in mortality after Massachusetts health care reform: a quasi-experimental study. Ann Intern Med 160:585-593, 2014.
3. Koroukian SM, Bakaki PM, Raghavan D: Survival disparities by Medicaid status: an analysis of 8 cancers. Cancer 118:4271-4279, 2012.
