In a recent funny and telling segment on the Jimmy Kimmel Live show broadcast on October 1, 2013 entitled “Six of One: ObamaCare vs. The Affordable Care Act,” people were asked about their preference for ObamaCare and the Patient Protection and Affordable Care Act (ACA). Most believed that these were 2 different health care programs, and had strong preferences for or against one or the other, likely based on ideologic convictions rather than an understanding of the provisions of the ACA. When asked about details, nearly all the respondents favored the components of the ACA while still objecting to “ObamaCare.”
As the ACA is implemented, controversy continues to surround it, with strongly held opinions existing regarding its eventual effect on health care in the United States. Depending on the wording of questions, surveys have demonstrated that 40% to 60% of Americans remain opposed to it because they are either convinced that it offers too little or too much. Despite the strong opinions, there are significant gaps in the understanding of what the ACA provides or stands for. Reviewing the premises of the ACA may help to clarify its potential impact on our health care.
We, the authors of this article, come from 2 states at the opposite ends of the health care spectrum: Massachusetts and Texas. The potential future of the ACA may be glimpsed through an assessment of the smaller-scale 2006 Massachusetts health care insurance reform law implemented by Governor Mitt Romney in April 2006. As a result of this law, citizens of Massachusetts now have affordable health insurance, with 99% of its residents covered. Approximately two-thirds of the state's adults say they support the reform. The program has tangible humane and economic benefits. It improves access to care. It increases people's ability to get jobs and children's ability to learn. It improves lives, provides peace of mind and economic security to families, increases productivity for large and small employers and for students, and (the bottom line) saves lives. It also creates jobs and contributes to the economic health of the state.[1, 2]
In contrast, 28% of Texans currently are uninsured, which is the highest uninsured rate in the nation. The ACA may provide insurance to approximately 3 million Texans, reducing the uninsured rate by one-half. Expanding Medicaid in Texas would provide insurance to an additional 1.5 million individuals, add nearly $90 billion to the state economy, boost economic output by $270 billion, and create nearly 200,000 jobs. Texas rejected the Medicaid expansion program.
The ACA offers several advantages for patients and their physicians. At least 30 million of the 50 million currently uninsured US citizens stand to gain health insurance coverage. Young individuals may remain on their parents' insurance until age 26 years. Insurance companies cannot deny coverage for preexisting medical conditions, cannot cancel insurance in the event of sickness, and cannot cap the amount of care received annually or during a patient's lifetime. Importantly for patients with cancer, they cannot deny coverage on clinical trials. The cost of care may be lower than caring for uninsured patients who would present at later stages of disease with more advanced cancers. The cost of medications is lower for senior citizens covered by Medicare (gradual closing of the donut hole). Insurance companies are required to spend 80% to 85% of collected revenues on actual health care, a figure previously as low as 50% to 60%. By comparison, Medicare spends 97% of its dollars on health care. The ACA Medicaid expansion (health insurance for the poor) may save 90,000 lives per year.
The ACA does not force individuals to change their insurance, as long as it provides the ACA requirements for minimum benefits, patient protection, and exclusion of significant deductibles. For example, some insurance policies do not include hospital care or emergency care; others have deductibles as high as $10,000 to $25,000 and require large copayments; still others cap coverage at $2000. Such insurances may not cover well patients during significant episodes of sickness. Policies like these may explain why 75% of patients who declare bankruptcy due to medical bills in fact owned health insurance at the time of their bankruptcy declaration.
What effect will the ACA have on oncology? The ACA broadens cancer care to millions more and expands Medicaid, thus covering more patients with cancer. This eliminates ethical dilemmas associated with their care. There is a direct correlation between a lack of insurance and increased mortality, and with presentation with later-stage cancers (presumably because patients do not have access to screening procedures and/or delay seeing physicians because of financial concerns).[8, 9] Extending insurance to more US citizens could help with earlier cancer diagnoses and improved outcomes. Free health care screening could allow for the detection of many cancers in earlier and possibly more curable stages (through mammograms, colonoscopies, Papanicolaou smears, computed tomography scans, etc). Patients who develop new cancers as a result of therapy for previous cancers or noncancerous conditions cannot be excluded. Insurers cannot deny coverage for investigational trials (which in many situations may be the best treatment for a particular patient). Insurance must cover at least 1 drug of each type, thus insuring broader treatment coverage for more cancers. The ACA closes the hole in Medicare Part B, which eliminates high out-of-pocket expenses for increasingly more common and expensive drugs. Coverage cannot be denied for technicalities (sometimes used to deny expensive care). Emergency room care, a frequent necessity in cancer care, will not require preauthorization, thus alleviating potentially harmful delays or the avoidance of emergency care for financial concerns. Physical therapy and rehabilitation, also important necessities in cancer care, are covered. Finally, there are no caps on annual or lifetime coverage for the cancer treatment, which can often be very expensive.
As with many such large-scale enterprises (Medicare, Social Security), the implementation of the ACA is experiencing both inherent and unforeseen problems. The initial experience with market exchanges and with the HealthCare.gov enrollment Web site was disappointing. Administrative issues still persist and frustrate users. Approximately 5% (10 to 12 million individuals) may have sub-optimal insurance policies described earlier. Some patients may not be able to keep the same physicians or be referred to the same hospitals they trusted and are used to (but this also happened with the previous system). Physicians may be paid less. They may be subjected to more quality reporting that influences their pay (which is also dependent on the adoption of electronic medical records). Some physicians may lose the autonomy of small (solo) practices and join larger groups or hospital-based practices to avoid risks and secure reasonable salaries. Whether the ACA implementation will actually raise or lower the costs and improve or worsen the efficiencies of the US health care system remain to be determined. Some analyses have suggested that insurance premiums may decrease on average by 10% to 18%, but this may be lower in some states and higher in others, depending on the state support of the health plan and its establishment of health care exchanges (facilitating the comparison of insurance plans).[10, 11]
The United States spends $2.7 trillion on health care (18% of the gross domestic product), twice as much as other developed nations without demonstrable additional benefits.[12, 13] The high cost of care is perceived to preclude universal insurance. However, the resources exist, except that they are not directed toward patient care but rather toward covering excessive bureaucratic and administrative costs, lobbying, advertising, and high profits to health care entities (hospitals, pharmacies, physicians, and pharmaceutical and insurance companies). A report by the Institute of Medicine and the National Research Council in 2013 ranked the United States last or near last in several health care categories among 17 countries studied. The authors were astonished at the findings, which are also not appreciated by the general public, because a commonly held belief is that the United States has the best health care system in the world. The report cited several explanations for the US health care disadvantage, including lack of health insurance. An analysis by the Commonwealth Fund also ranked the United States last among 7 countries in health care performance. The United States ranked well in cancers such as those of the breast, prostate, and cervix, in which superior survival results may be artifacts of earlier diagnosis. However uninsured patients with nearly all types of cancers were noted to present with later stages of disease and to have higher mortality rates. Based on these findings, an obvious way to improve outcomes in patients with cancer in the United States is to have broader insurance coverage that includes the current 15% of US citizens who are uninsured.
While upholding the ACA, the Supreme Court allowed states to reject the federally funded expansion of Medicaid (23 states to date, all with Republican governors, have rejected coverage for lower-income patients). This makes its national implementation more difficult. As planned, the US government will provide approximately $1 trillion over 8 years (2014-2022) to states that accept the Medicaid expansion; of this money, all states provide approximately $76 billion. The federal government supports the expansion at a 100% level for the first 3 years, phasing down to 90% in 2020 and all subsequent years. Some studies have shown that expansion of Medicaid may substantially decrease mortality rates by approximately 90,000 lives.[5, 18] Rejection of Medicaid expansion in states that opted out might result in more than 20,000 lives lost per year. Denial of Medicaid coverage expansion disproportionately affects certain vulnerable groups, including two-thirds of poor blacks and single mothers, and one-half of low-income workers who did not have previous health care coverage.
One reason for the rejection of Medicaid expansion by several states is the possibility that it will increase costs. In fact, it brings a large infusion of new money and jobs while reducing unpaid bills for treating low-income patients. The Medicaid expansion gives health coverage to millions who currently have none and who receive interrupted suboptimal care in emergency rooms or in “safety-net” hospitals. This increases the cost of care by multiple folds, results in worse outcomes and more deaths, and adds to the taxpayers' burden.
Some experts argue that Medicaid insurance may be associated with worse outcome compared with private insurance, Medicare, or no insurance. Poor patients covered by Medicaid face hardships that prevent compliance with optimal care (eg, out-of-pocket medical costs, transportation costs, inability to take off work, and childcare issues). However, research confirms that Medicaid coverage improves outcome and reduces mortality compared with having no insurance.[16, 18]
Regardless of the advantages of, and issues with, the ACA, a change in the US health care system is needed. The previous system left too many citizens out of the health care safety net, individuals who were highly vulnerable in the event of illness. Today, all developed nations provide their citizens with universal access to affordable health care; this is considered a moral obligation, part of social justice. The United States is the only exception.
Within the context of cancer care, numerous studies have shown that reducing access to care (eg, poverty, lack of insurance) significantly affects treatment outcomes adversely, and increases disparities in cancer care.[19-23] For example, the worse outcomes noted among African Americans receiving cancer treatment has now been correctly attributed to socioeconomic factors and other disparity measures, not to racial differences in biology.[19-23] To put it simply, no treatment works if it is not given.
Most oncologists know of patients who were denied access to needed care, received delayed treatment, or were harmed or humiliated by the process. Oncologists face this moral dilemma on a daily basis with new patients diagnosed with cancer who are uninsured. Today, one-third of patients with leukemia treated by one of us (H.K.) are uninsured or with insurance that limits care significantly (eg, cap on costs, cancellation of insurance for various reasons, or denial of cancer care on “investigational” therapies). It is our view that the ACA offers oncologists the ability and peace of mind to deliver the best care available without worries about compromises related to economic issues.
The ACA has many flaws that need to be addressed, but it is a step in the right direction. As it is implemented, we can assess its benefits and possible unintended ill effects. These can be remedied with additional legislation, as was done with Social Security and Medicare. As oncologists, we are guided by the Hippocratic Oath, which contains 2 passages addressing injustice (personal and social), and which states: “But from what is to their harm and injustice I will keep them.” This emphasizes the 2 most important tenets of the Oath: beneficence and justice. It is our obligation as physicians to keep patients from harm (lack of insurance, lack of affordable therapy, death) and injustice (differential care based on finances). As a society, we will be judged by how well we care for our most vulnerable individuals, in this case the sick. Oncologists should advocate for the ACA and work on improving it. Waiting for the perfect ACA may mean no care for far too many.