Despite ACA Coverage, Cancer Patients Still Struggle to Pay

Roxanne Nelson, BSN, RN

July 25, 2017

Despite improvements in healthcare law, cancer patients in the United States are still struggling with significant financial challenges.

The passage of the Affordable Care Act (ACA) guaranteed insurance coverage to individuals with preexisting conditions, and thus allowed cancer patients and survivors access to care that they might not have been able to otherwise afford.

But according to a new report released by the American Cancer Society Cancer Action Network (ACS CAN) and the Center on Health Insurance Reforms, Georgetown University, cost sharing in the form of higher deductibles, coinsurance, and copayments has increasingly shifted the financial burden to patients.

"The current health law has greatly improved access to meaningful health coverage for cancer patients, survivors, and all those with chronic diseases," said Chris Hansen, president of the ACS CAN, in a statement. "Yet costs remain a challenge for those facing cancer. Our country and our lawmakers should come together to find bipartisan solutions that begin to address patient costs without sacrificing the quality of coverage."

Before implementation of the ACA, cancer patients had to deal with significant barriers to obtain health insurance if they did not have coverage through an employer or a government program such as Medicare.

Patients and cancer survivors who had to purchase individual market health plans often found that the premiums were unaffordable and that out-of-pocket costs were prohibitive. The passage of the ACA helped by making individual coverage more accessible and affordable for those with low and moderate incomes by providing subsidies for premiums and out-of-pocket costs. The law also requires that all plans must include caps on annual out-of-pocket costs, with caps of $7150 for an individual plan and $14,300 for a family plan (2017 rates).

Costs Add Up

Despite the improvements in access and annual caps on out-of-pocket spending, cancer patients are still struggling with expenses related to their care. A study by the ACS CAN and the Center on Health Insurance Reforms in April found that $4 billion was spent out of pocket for cancer care in 2014, amounting to 4% of the total $88 billion spent on cancer-related healthcare that year.

In the April report, three hypothetical cases are presented. In the first case, a breast cancer patient with employer-sponsored insurance spent $1844 on premiums and $3975 out of pocket toward a total $144,193 in treatment costs. A colorectal cancer patient with Medicare and a Medigap policy paid higher premiums — $7205 — and lower out-of-pocket costs, at $1368, for treatment costing $124,425.

The third patient, who had lung cancer, was insured through the ACA health exchanges and had the highest out-of-pocket expenses: $3264 in premiums and $6850 in copays and coinsurance. The total cost of treatment of $210,067.

Affordability and Obstacles

The current report, Navigating the Coverage Experience and Financial Challenges for Cancer Patients, summarizes the experiences of cancer patients who have worked with financial navigators at 11 US hospitals in nine states. Interviews were conducted with 13 financial navigators at 11 hospitals, with the focus being on patients covered by private insurance through an individual or employee plan.

The locations of the hospitals ranged from mid-size and large cities to facilities in less populated, rural areas.

The report found that cancer patients tend to meet the spending limits for deductibles and out-of-pocket expenses very quickly, because of the substantial costs of cancer care.

In addition, the "clock resets" each January for these spending caps, and thus the timing of cancer diagnosis can significantly affect a patient's ability to pay for their care. One financial navigator who was quoted in the report said, "Unfortunately, for those that are diagnosed toward the end of the year, [they] have to meet their deductible and begin again in January."

The length of treatment also plays a role. Some cancer patients may need to meet deductibles and pay maximum out-of-pocket costs for several years in a row. Another financial navigator noted, "The average people I work with don't have money saved, and if they do, it's minimal. Having to meet out-of-pocket costs three years in a row — it's $15,000, not $5000."

In addition to the direct out-of-pocket expenses, patients face other barriers to access.

Although insurance generally covers most cancer treatments, payers have been increasingly implementing requirements for medical management. These include prior authorizations or step therapy, which require that a less expensive drug be tried before the insurance company will pay for a higher-cost treatment.

According to the financial navigators, the higher-cost oral oncologic agents and newer drugs are the ones that most frequently require prior authorization or step therapy.

"Cutting-edge cancer drugs are on the formulary, but have limitations," noted one financial navigator, such as step therapy or being placed on the highest cost-sharing tier.

Future of Cancer Care

The report cautions that the current proposals being debated in Congress could significantly erode the coverage offered under the ACA, as reported by Medscape Medical News, and additional costs may be shifted to patients.

If passed in its present form, patients will likely end up with higher deductibles and out-of-pocket costs under these new healthcare policies.

The report notes that both cancer patients and survivors who are uninsured or who are losing job-based coverage could "lose guaranteed access to comprehensive, affordable coverage under proposals to weaken the ACA's protections for people with pre-existing conditions."

In addition, access to prescription drugs and other essential care could be at risk if insurers are granted greater flexibility to define covered benefits, and for many patients, coverage itself could become unaffordable if premium tax credits are scaled back, out-of-pocket assistance is eliminated, or the age rating is expanded.

If the cap on out-of-pocket costs and if prohibitions on annual and lifetime spending limits are weakened or eliminated, the resulting costs for cancer patients and survivors could be catastrophic.

The report was supported by a grant from the ACS CAN.

ACS CAN and the Georgetown University Health Policy Institute. Navigating the Coverage Experience and Financial Challenges for Cancer Patients: Affordable Care Act Brings Improvements, But Challenges Remain. Full text

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