In the spring of 2008, while I was finishing my oncology pharmacy residency training, I had the opportunity to spend a month in a prominent urban hospital very well known for its indigent patient population. Although this experience was primarily focused on learning standard-of-care oncology without cutting-edge investigational therapies and the latest US Food and Drug Administration (FDA)-approved drug options, what stands out in my mind are the patients I saw who were unable to receive the care they desperately needed due to a lack of health insurance. One patient in particular was denied a much-needed stem-cell transplant because the cost of the procedure exceeded his meager insurance policy’s lifetime maximum spending limit. It was, and remains today, one of the fundamental reasons why I developed an interest in providing services and access to care for underserved populations.
Unfortunately, such situations are not unique in oncology practices in this country. Although we would like to think of these issues as being relegated to the farthest reaches of rural communities or inner cities, it is simply not true. In fact, regardless of the socioeconomic status of a patient or the quality of the health insurance plan to which one is subscribed, there will inevitably be issues related to ensuring coverage and payment for therapies that, as providers, we can scientifically defend the rationale for prescribing. The system ensures an unmet need for some patients while allowing healthcare spending to explode in an unsustainable model. Although most providers would agree that the system needs to be revamped, not all would agree on the methods for reforming healthcare in the United States. My objective, then, is not to further politicize a highly emotionally charged topic but rather to evaluate the impact of the Affordable Care Act (ACA) on the delivery of oncology services in as objective a manner as possible.
First, the Congressional Budget Office estimates that as of April 2014, the ACA has decreased the number of uninsured nonelderly adults by 12 million, and, by 2019, the decrease will be 26 million.1 Given the fact that cancer is one of the major causes of mortality in the United States,2 the ACA will, hopefully, allow more patients with cancer to seek care and especially to seek care earlier, when treatment may offer a greater chance of survival.
Second, the ACA’s provision for allowing children to remain covered by a parent’s health insurance plan until age 26 years will ensure that college-age Americans are not lost in the vacuum of the now outdated healthcare system. Estimates suggest that people in the age range of 18 to 34 years historically were uninsured at twice the rate of older Americans.3 Although individuals in this age range have a low incidence of cancer, those diagnosed often faced an inability to pay for the care they needed.
What about the impact on drug therapy and pharmacy specifically? With the implementation of Medicare Part D, many older Americans were provided with insurance coverage for oral medications. A notable deficit in these plans was the so-called “doughnut hole,” which required patients to pay, at times, unaffordable amounts of money out of pocket in order to ensure that their treatment remained uninterrupted. The ACA plans to reduce, and ultimately close, this coverage gap. With the growing percentage of orally administered chemotherapy drugs, coverage for these expensive medications becomes much more significant. To date, oral chemotherapy parity legislation has been enacted in 33 states plus the District of Columbia, but further assurance of access to care for these medications is essential, especially considering that 25% to 30% of all new oncology drugs in development are administered orally.4 The ACA plans to do just that.
In addition, the ACA offers assurance that patients may participate in clinical trials of investigational therapies without fear of losing their insurance plan or finding a lack of insurance coverage for drugs received in this setting. Given that many professional oncology organizations and clinical practice guideline groups recommend consideration of clinical trials for virtually every patient diagnosed with cancer, eliminating access to these studies would seem to breach the Hippocratic Oath of “Do no harm.” During this era of (some) insurance plans that prevented coverage for their subscribers who elected to join a clinical trial, many patients were refused access to drugs which, while not yet FDA approved, frequently had demonstrated efficacy in other, earlier human studies. This advance opens clinical trial access to many more patients, which may prove beneficial not only for current patients but for future generations of patients as well.
Do I think that the ACA will resolve all of our healthcare system issues? No. However, there are aspects of the ACA that I believe will increase access to high-quality cancer care for a larger proportion of the population. Likewise, as providers, we will be challenged to become more efficient and to, arguably, do more with less. We will be required to demonstrate a more evidence-based approach to cancer care, we will be encouraged to explore more cost-effective therapies when guidelines allow for interchangeable options for equally staged patients with cancer, and we will be challenged to provide higher quality care lest our patients “bounce back” and reimbursement be reduced for subsequent hospitalizations. Furthermore, adding an additional 30 million Americans to the currently stressed healthcare system will require thinking outside of the box regarding the management of patients, which should create better opportunities for multidisciplinary cancer care delivery. I envision a system with the oncologist as the head of a team and nurses, nurse practitioners, physician assistants, and clinical pharmacists shouldering a greater percentage of direct patient care within a setting of collaborative practice agreements. When each member of the healthcare team is allowed intellectual freedom to practice to the highest levels of their licensure and certification, job satisfaction is improved and patient care is bettered by empowering each person to truly take ownership of the services they have been trained to provide. Although the ACA is not perfect and there is certainly room for modification, growth, and improvement, there are some highlights that should allow us to help more patients who may have historically been left on the outside of the healthcare system looking in.
- Congressional Budget Office. Insurance coverage provisions of the Affordable Care Act—CBO’s April 2014 baseline. http://www.cbo.gov/sites/default/files/cbofiles/attachments/43900-2014-04-ACAtables2.pdf. Accessed October 25, 2014.
- Centers for Disease Control and Prevention. Leading causes of death. Updated July 14, 2014. http://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm. Accessed October 23, 2014.
- Postolowski C, Newcomer A. Helping students understand health care reform and enroll in health insurance. Young Invincibles website. June 2013. http://health.younginvincibles.org/wp-content/uploads/2013/09/ACA-Toolkit_Helping-Students-Understand-Health-Care-Reform-and-Enroll-in-Health-Insurance.pdf. Accessed September 11, 2014.
- Stephan GM. Update on parity laws for chemotherapy. Wolters Kluwer Financial Services website. May 6, 2014. www.insurancecompliancecorner.
com/update-on-parity-laws-for-chemotherapy-2/. Accessed September 11, 2014.