At 10 Years, ACA a Boon to Patients With Cancer, With Some Snags

Roxanne Nelson, RN, BSN

March 12, 2020

The Affordable Care Act (ACA) celebrates its 10th birthday this month.

While far from perfect and almost continuously challenged, the law has expanded healthcare coverage for millions of Americans, and in particular, provided essential health benefits to cancer patients and survivors.

"One of the greatest benefits of the ACA was that cancer patients could get health insurance and no longer be discriminated against," said Kirsten Sloan, vice president of public policy at the American Cancer Society Cancer Action Network.

Prior to the ACA, anyone with a preexisting condition, whether it was a skin condition, cancer, or heart disease, could legally be denied coverage. Under the ACA, insurers were obligated to cover everyone, whether they were healthy or had an underlying condition.

However, health insurance in the US is generally expensive; the ACA is getting more expensive for many people with cancer as the Trump administration eliminated the "individual mandate" (ie, everyone must have health insurance), which has caused prices to rise for those left in the market (ie, those who cannot run the risk of no insurance, including older adults and those with acute or chronic illness). In short, the ACA, especially as weakened by the current administration, is still inaccessible for many cancer patients.

"The second key benefit is that the ACA did away with annual limits in coverage and there was no lifetime limit," said Sloan in an interview, noting that before the ACA was passed, many insurance companies had lifetime limits on coverage, which were generally around $1 million. Once reached, individuals were then responsible for paying the full cost of the healthcare.

"Another key benefit was that children could stay on their parents plan until the age of 26," Sloan noted. "This was especially beneficial to pediatric cancer patients, that their coverage continued uninterrupted."

Studies have also shown that young adult patients have been diagnosed earlier and accessed treatment sooner due to improved access to health coverage, she added.

Under the ACA, insurers could no longer drop patients from plans if they got sick. This used to be a fairly common practice, which insurers called "rescission." They would look for and exploit technical errors, or "tell you that you forgot to check a box," said Sloan, "And use that as an excuse."

Another mandate of the ACA was also to provide screening at no cost. "All insurers must cover cancer screening tests without a copay," she said.

Finally, a cornerstone of the ACA was Medicaid expansion, in order to provide realistic access to healthcare to as many people as possible. Under this provision, Medicaid eligibility was extended to adults up to age 64 with incomes up to 138% of the federal poverty level. In addition to Medicaid expansion, the ACA also provided subsidies to help pay for healthcare coverage.  The subsidies were slated to the population who earned too much money to qualify for Medicaid, but still could not afford health insurance plans.

Medicaid and Marketplace

The American Cancer Society notes that patients in Medicaid expansion states are now less likely to be uninsured, more likely to get a proven cancer screening, and less likely to report being unable to afford their care. Medicaid expansion has also reduced disparities along ethnic, racial, and urban and rural lines.

"Cancer patients who gained insurance as a result of Medicaid expansion typically had no other affordable options prior to the ACA," said Coleman Drake, PhD, assistant professor in the Department of Health Policy and Management at the University of Pittsburgh in Pennsylvania. "For them, health insurance is typically free with no or very little copays and deductibles."

He noted that the Marketplaces are still quite important and provide around 12 million Americans with insurance this year. "A misperception about the Marketplaces is that enrollees are harmed by the large premium increases that have occurred since 2017," he told Medscape Medical News. "For the large majority of enrollees that receive advanced premium tax credits, the premium of a typical 'benchmark' plan is capped as a percentage of household income, ranging from about 3% for households at the poverty line to about 10% for households at 400% of the Federal Poverty Level or about $50,000 for an individual."

These criteria have not changed since 2014, meaning that Marketplace plans have remained relatively affordable for subsidized enrollees. "In addition, a 'silver loading' actually significantly increased affordability for Marketplace enrollees starting in 2018," he said.

Silver loading is a complex process that insurers have used to fill the gap, so to speak, left by the federal government. The ACA required that insurance companies provide cost-sharing reductions (CSRs) for consumers with incomes below 250% who enroll in silver-tier Marketplace plans. The goal of the ACA was that the federal government would reimburse insurers for the cost of CSRs, but this program ended in 2017.

However, Marketplace insurers were still required to provide CSRs to eligible consumers and thus they built the cost of CSRs into premiums. This practice became known as "silver loading," and ensured that insurers are still compensated. In addition, it lowered premiums for many people.

Not Quite Affordable

Unfortunately, the ACA has had some unintended consequences and has made healthcare more expensive for many, rather than more affordable.

According to the Department of Health and Human Services (HHS), "premiums have doubled for individual health insurance plans since 2013, the year before many of Obamacare's regulations and mandates took effect."

Data on the website show that average individual market premiums more than doubled from $2784 per year in 2013 to $5712 in 2017, an increase of $2928 or 105%. Alaska, Alabama, and Oklahoma saw premiums triple in that time.

Although the ACA significantly halved the number of people without health insurance from over 46.5 million in 2010 to just below 27 million in 2016, that number has begun to creep up. Even though it is substantially lower than before the ACA was implemented, the number of uninsured rose by 1.2 million since 2016, when it reached a historic low. In 2018, 27.9 million people were uninsured, which was an increase of nearly 500,000 from 2017.

"Patients whose household incomes exceed 400% of the Federal Poverty Level do not receive advanced premium tax credits," said Drake. "Unlike their lower income counterparts with subsidies, they are exposed to premium increases and these premium increases were quite large in 2017 and 2018."

These premium increases were the result of a number of factors, he explained, notably that individuals using the Marketplace "turned out to be a bit sicker than insurers anticipated" as compared to those who receive insurance from their employer.

"Second, the Trump administration has pursued a number of policies that have made unsubsidized Marketplace plans increasingly unaffordable, including the elimination of the individual mandate, huge cuts to Marketplace advertising and outreach, and the introduction of short-term, limited-duration health plans," Drake said. "All of these policies destabilize the market by pulling healthier enrollees out of the market and premiums are then adjusted to account for the relatively sicker health profiles of remaining enrollees, a significant amount of whom have chronic and life-threatening health conditions."

Out-of-Pocket Expenses Go Up and Up

Even with the ACA, out-of-pocket costs can be formidable for cancer patients and survivors. A study published last year from the Centers for Disease Control and Prevention (CDC) found that 25% of survivors reported problems paying medical bills, and 33% reported worry about medical bills.

"Out-of-pocket expenses are a significant challenge for people earning over 200% of the federal poverty level," said David Anderson, MSPPM, research associate at Duke University's Margolis Center for Health Policy in Durham, North Carolina. "And premiums are a significant challenge for individuals earning over 400% of the federal poverty level."

The large deductibles are also a challenge, although there was a trend in that direction prior to the ACA. "But even though the deductible is far less expensive than [the amount] one would pay out-of-pocket for cancer treatment, paying $8500 all at once can be a huge hit for many," he explained. "And the out-of-pocket costs can be very high for cancer patients."

Anderson emphasized that this is a different world now, as treatments have changed from those in the past. "Cancer can now be a long-term chronic condition, where patients may be on treatment for years, with high out-of- pocket costs for the drugs," he emphasized. "Our payment system has not caught up with the technology. It's a good thing that patients are living so much longer, but it can be expensive."

Importantly, the ACA has not fundamentally touched price levels. "There is very little cost regulation, outside of the annual limits," he said.

But on average, Anderson believes that the ACA has significantly improved the lives of cancer patients "compared to the counterfactual world of no ACA and no major changes to the 2009 status quo," but this improvement is not uniform.

"There are some cross-currents at work," he added. "We still would have seen the revolution in branded drug treatments and the concurrent spike in prices without guaranteed-issued, community-rated insurance that has no lifetime nor annual limits."

More Affordable

Sloan, from the American Cancer Society, agrees that affordability is an issue, as cancer patients are "high utilizers" of healthcare. "Cancer patients are keenly aware of the cost of their care," she said, "And that is something that the American Cancer Society is striving for — to make that coverage more affordable."

The ACA was passed on March 23, 2010, and to coincide with the 10th anniversary, Speaker of the House Nancy Pelosi is preparing to unveil a sweeping plan to lower the cost of healthcare, according to the New York Times. The new legislation veers away from the "Medicare for all" plan that has been proposed by some Democrats, and instead is aimed at reducing costs under the current health bill.

While the details have not been announced, Pelosi is expected to propose a series of steps that will make healthcare more cost-effective under the ACA. This may include expanding tax credits and subsidies that will help people buy insurance as well as creating a national program to help cover expenses for those with medical conditions.

California assembly member Jim Wood (D) isn't waiting for the federal government to act. Last month, he introduced state bill AB 2347, which will reduce the cost of healthcare coverage for millions of residents who purchased their insurance through Covered California, the state's healthcare exchange for the ACA.

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