2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

Core Elements of the Patient Protection and
Affordable Care Act and Their Relevance to
the Delivery of High-Quality Cancer Care
By Beverly Moy, MD, MPH, Amy P. Abernethy, MD,
and Jeffrey M. Peppercorn, MD, MPH
Overview: The Affordable Care Act (ACA) contains many
provisions that affect cancer care. The provisions of health
care reform aim to improve access to quality cancer care,
particularly among the most vulnerable Americans. However,
health care reform also offers many challenges and opportu-
IN MARCH 2010, President Obama signed into law the
Patient Protection and Affordable Care Act (ACA). 1,2 The
ACA contains provisions that have important implications
for cancer care. 3 Its implications for patients are sweeping
and have the potential to expand access to care and improve
cancer care among vulnerable groups. The ACA, although
not perfect, aims to make cancer care more comprehensive,
affordable, and accessible. This article provides an overview
of the ACA in relation to oncology, discusses the ethical
challenges for the oncology provider, and summarizes issues
relevant to various stakeholders in the oncology community.
Overview of Cancer Care and the
Affordable Care Act
Insurance Reforms
In 2008, there were an estimated 46.3 million uninsured
Americans, equaling 15% of the United States population,
plus an additional 25 million underinsured Americans. 4,5
According to the Congressional Budget Office, the ACA is
expected to expand health insurance coverage to 32 million
individuals by 2019. 6
Medicaid
The ACA expands Medicaid to individuals with incomes
up to 133% of the federal poverty level (FPL), thereby adding
16 million to 20 million individuals to the Medicaid roster.
The ACA also standardizes Medicaid benefits by guaranteeing
a minimum package of essential services. However,
oncology provider participation in Medicaid is in jeopardy,
particularly in states that are economically poorer as a
result of low reimbursement levels. Currently, some states
are reporting additional cuts in Medicaid payments, further
reducing the value of this coverage. Also of major concern is
that there is convincing evidence that adult patients with
cancer with Medicaid have similarly poor clinical outcomes
compared with those of uninsured patients. 7-10 Therefore,
Medicaid expansion would not necessarily be expected to
improve cancer outcomes among vulnerable populations as
the system currently stands. Given the anticipated expansion
in the Medicaid population, the quality of care under
the Medicaid program may be further compromised.
Health Insurance Exchanges
By 2014, health insurance exchanges must be established
in all states. These exchanges are designed to provide
individuals or small businesses the opportunity to shop for
health insurance.
e4
nities that affect every stakeholder in oncology. This article
summarizes the ACA provisions relevant to oncology, discusses
the ethical implications for the oncology caregiver,
and describes the effects on specific oncology stakeholders.
Elimination of Coverage Barriers
The ACA prohibits insurers from denying coverage to
children with preexisting medical conditions and allows
young adults up to age 26 to remain on their parents’ health
plans. Starting in 2014, all insurers will have to accept
all applicants, irrespective of preexisting conditions such as
cancer, and renew coverage. The law prohibits canceling
coverage, eliminates the lifetime amount insurance will
pay for certain conditions, and restricts annual limits. Patients
with cancer and survivors of cancer will not be denied
coverage on the basis of their preexisting diagnosis of
cancer.
Medicare “Donut Hole”
The ACA helps to close the so-called Medicare donut hole
so that seniors do not face a costly gap in prescription drug
coverage. This is especially relevant in cancer because many
modern anticancer therapies are now in oral form and can be
prohibitively expensive. Each eligible senior will receive a
one-time, tax-free $250 rebate check.
Pediatric Cancer
In aggregate, childhood cancer is the sixth most common
cancer in the United States. The ACA specifically mandates
that Medicaid-eligible children who voluntarily opt for hospice
services will no longer be required to forego curative
services, such as active cancer treatment, to receive hospice
care coverage.
Cancer Prevention and Survivorship
Early detection of cancer through adherence to recommended
screening examinations leads to decreased mortality
from most cancers. The ACA requires all health plans to
cover preventive services that receive an “A” or “B” rating
from the U.S. Preventive Services Task Force (USPSTF).
These treatments must be covered with no deductibles or
copays and with no maximums allowed. However, the ACA
does not expressly require insurers to cover follow-up testing
of abnormalities found in a cancer screening examination.
The ACA also does not comment on reimbursement for
From the Massachusetts General Hospital Cancer Center, Boston, MA; and Duke
Comprehensive Cancer Center, Durham, NC.
Authors’ disclosures of potential conflicts of interest are found at the end of this article.
Address reprint requests to Beverly Moy, MD, MPH, Massachusetts General Hospital,
55 Fruit St., YAW 9A, Boston, MA 02114; email: bmoy@partners.org.
© 2012 by American Society of Clinical Oncology.
1092-9118/10/1-10