ACA Hardly Made a Dent in Catastrophic Cancer Costs

Sara Goudarzi

September 28, 2021

The enactment of the Patient Protection and Affordable Care Act (ACA) did not greatly reduce the risk for catastrophic health spending in the nonelderly cancer population, but it did lower the risk for loss of or change in insurance coverage, known as churn, according to a new study.

The out-of-pocket costs of cancer treatment are notoriously high, and cancer patients often go to extreme lengths to find and pay for treatment, said lead study author Benjamin B. Albright, MD, research fellow in the Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina. Albright noted, for instance, that he recently prescribed a new chemotherapy treatment for a patient that comes with a $3000-a-month copay.

The ACA aimed to limit the financial implications of cancer and other high-cost conditions, especially for those with lower incomes who are "obviously at higher exposure to financial toxicity related to their ongoing cancer care," Albright said.

Albright and colleagues wanted to understand whether the ACA provisions and programs did, in fact, reduce the risk for insurance churn and out-of-pocket costs for patients with cancer.

The findings are detailed in Jama Open Network.

Using the Medical Expenditure Panel Survey (MEPS), a representative sample of the US population conducted annually, the researchers evaluated health expenditures and insurance status of 6069 cancer patients who were younger than 65 years between 2005 and 2018. They compared data from the pre-ACA period (2005–2009) with data from the full ACA years (2014–2018). Catastrophic health expenditures were defined as out-of-pocket spending of 10% or more of an individual's annual family income. The data contained details regarding healthcare-related expenditures, income, and medical diagnoses.

The study authors found that between 2005 and 2018, patients with cancer experienced about 1.5 to 2 times the risk for catastrophic health expenditures overall compared to patients without cancer. Patients with cancer had a 12.4% risk for catastrophic health expenditures, vs 6.3% in the population without cancer. When factoring in spending on insurance premiums, the risk for catastrophic health expenditures more than doubled (26.6%) among those with cancer in comparison with those without (16.5%).

For cancer patients, ACA implementation was associated with 4.2% decreased annual risk of having no insurance and 3% lower risk for catastrophic health expenditures for expenses. However, when including insurance premiums, the authors found no statistically significant declines in catastrophic health expenditures after ACA implementation.

"While the Affordable Care Act clearly had some benefits for patients in terms of having lower risk of uninsurance [no insurance] and reducing the average number of months uninsured in a given year, we did not see reductions in the cancer population in the risk of catastrophic spending," said Albright.

Although the investigators could not attribute the results solely to the implementation of the ACA, Albright explains that the survey — designed to be representative of the full US population — does describe what is happening to those with cancer.

Although the survey provides insight into trends about cancer coverage and costs within a large patient population, there are nuances that such a large survey misses.

"Coverage — even ACA coverage and what Medicaid covers or is even allowed to do — is very heterogeneous on a state-by-state basis," said Ramy Sedhom, MD, assistant professor of hematology and oncology, Perelman School of Medicine, the University of Pennsylvania, Philadelphia, Pennsylvania, who was not involved with the study. "Without really diving into individual states, it's very hard to tease out meaningfully what this actually means."

States have different policies, based on Medicaid and Medicare laws, regarding generic drugs, which makes it hard to understand how costs are affected.

Moreover, the costs associated with access to care are difficult to determine from such a database. Take costs associated with travel. A 2020 study published in Jama Oncology found that cancer patients can pay up $1680 in parking fees over the course of their treatment.

In addition, "when you live in some of the more rural parts of America — where you're dependent on a safety net hospital — you could be in parts of the state where you have to drive 4, 5 hours to get cancer care, and just the costs associated with that or places to stay are really hard to quantify and identify," Sedhom said.

The MEPS database also doesn't provide information about where a particular patient might be in the course of their cancer care. Patients could be newly diagnosed, under active treatment, or in remission. All of these factors affect a patient's spending.

The study does raise important questions that could have implications in policymaking at both federal and state levels.

"Work like this is very informative on how policies are either improving or not meeting the outcomes of insurance of what they're supposed to do," Sedhom said. "It's a good reminder that, while we are taking steps forward, there's always so many little things, and the devil's in the details, of how to improve our patient outcomes."

Coauthor Laura J. Havrilesky, MD, MHSc, has received grants from AstraZeneca and Tesaro outside the submitted work. No other relevant financial relationships have been disclosed.

JAMA Network Open. Published online September 8, 2021. Full text

Sara Goudarzi is a Brooklyn-based writer whose work has appeared in The New York Times and Scientific American, among other publications. Her debut novel, The Almond in the Apricot (Deep Vellum), is due out in January 2022.

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