The Affordable Care Act (ACA), officially called the Patient Protection and Affordable Care Act,1 which began implementation in March 2010 and will not be fully implemented until 2018, has impacted oncology care in both positive and negative ways. This legislation provides opportunities for addressing disparities in cancer care, and it has the potential to expand access to care and improve services among vulnerable groups.2 However, the ACA alone cannot eradicate the problem of cancer disparities but instead builds a new foundation for creating meaningful policy changes.
The goal of the ACA was to increase access to care for the 46 million Americans who were uninsured3 for reasons varying from being excluded from the insurance pool because of preexisting conditions, being “young immortals” who electively defer insurance coverage when healthy, or being unable to afford insurance options. Although the ACA is far from a perfect piece of legislation, in many ways it has helped overcome barriers to cancer care.
The elimination of preexisting conditions as a barrier to insurance coverage has definitely aided patients with active cancer or a history of cancer. Patients with active cancer were essentially uninsurable if they did not have insurance prior to the cancer diagnosis, and many patients who had a history of cancer could not obtain affordable health insurance to allow them to obtain necessary testing to monitor for recurrence of the disease or manage late complications related to treatment.
The availability of public exchanges in 2014 and Medicaid expansion, though both flawed in their implementation for multiple reasons, have succeeded in creating access to care not previously available. It has been estimated that the pool of uninsured patients has been reduced by as little as 9.5 million to as much as 16.5 million, depending upon how the figure is calculated and the organization’s political goals.4 What is known is that the percentage of the US population that is uninsured has dropped from a peak of 18.0% in the third quarter of 2013 to 13.4% in May 2014.5 The federal government now requires states to offer Medicaid to people with incomes up to 138% (133% plus a 5% income disregard) of the federal poverty level (FPL), with most of this expansion funded federally.1 In addition, it offers subsidies to help those with incomes up to 400% of FPL to purchase private insurance through newly created insurance exchanges.1 Therefore, many patients who could not afford insurance have been able to purchase insurance at affordable prices. Both of these initiatives remain highly politically charged, with many states not opting to expand Medicaid or to assist in development of their state exchanges, which has complicated patient access and has maintained geographic disparities in care.
Another less recognized aspect of the ACA that has positively impacted patient care—and, by extension cancer care—is the requirements for health insurers to provide information to potential and established members that is linguistically and culturally sensitive.1 The ACA also requires that translation services must be paid for if not directly provided by the insurer. This allows patients better comprehension of their care, alleviating anxieties and resistance that may otherwise occur. It also allows them to understand their benefits in a way that makes them more comfortable in accessing appropriate care.
The authorization of increased funding for community health centers has also helped to increase patient access to care, as these facilities are able to expand services frequently accessed by minorities and other culturally marginalized patients who have had difficulties navigating other community resources. This has the potential to result in increased health screening for colorectal, prostate, and breast cancer, which should result in earlier cancer detection with resultant improved health outcomes and reduced societal costs.
Finally, the preventive mandates put forward in the ACA have reduced another barrier related to cancer detection. The ACA requires qualified health plans to provide certain services with either an A or B recommendation by the US Preventive Services Task Force, and specific services/therapies related to women’s health, with no cost share to the member.1 This has increased the number of individuals obtaining colorectal and breast cancer screening and undergoing BRCA testing. It is too early to assess whether this has improved the overall health of the population, but it certainly has impacted individual outcomes, as a greater number of individuals for whom cost was a barrier are obtaining testing.
It is important to note that not all impacts from the ACA have been positive for patients or providers. Despite efforts to increase access to quality healthcare, it did not adequately address the other large issue in the United States—affordability. Healthcare in the United States remains the most expensive in the world and yet health outcomes are average in many areas at best. The reimbursement incentive still targets volume, not value, although some shift is occurring. The cost of healthcare is increasing, athough the rate of increase has slowed in the last several years.2 The various mandates in the ACA have resulted in increased cost to employers and plan holders, resulting in continued cost-shifting to individuals through high-deductible health plans or defined-contribution plans. As oncology care costs continue to rise at a rate disproportionally above the cost of other healthcare costs, due to the extreme pricing tactics of pharmaceutical manufacturers, and as more care is undertaken, some patients are placed in the position of foregoing necessary care.
Additionally, the lack of uniformity across states with regard to the benefits of the exchange plans, the presence of “grandfathered” plans, “grandmothered” plans, and different metal levels for exchanges have resulted in persisting or greater confusion for patients and providers as to what is covered when. This confusion has added to the inertia of care, and, in some instances, patients forego cancer therapies due to confusion.
Overall, it is my belief that the positive impacts have outweighed the negative impacts at this point in the implementation of the ACA. As more aspects of it are implemented, we will see if this holds true. Certainly, the midterm elections may have an impact on the ACA, and what impacts will “ripple” out to patients and providers is unknown at this time.
- Patient Protection and Affordable Care Act of 2010. Public Law 111-148, 124 Stat 119, 2010.
- 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. 2011;29:3816-3824.
- DeNavas-Walt C, Proctor BD, Smith JC. Income, Poverty, and Health Insurance Coverage in the United States: 2008. US Census Bureau, Current Population Reports, P60-236. Washington, DC: US Government Printing Office; 2009.
- Collins SR, Rasmussen PW, Doty MM. Gaining ground: Americans’ health insurance coverage and access to care after the Affordable Care Act’s first open enrollment period. Issue Brief (Commonw Fund). 2014;16:1-23.
- Levy J. U.S. uninsured rate drops to 13.4%: uninsured rate down nearly four percentage points since late 2013. Gallup website. May 5, 2014. www.gallup.com/poll/168821/uninsured-rate-drops.aspx. Accessed October 22, 2014.