Will the End of Obamacare Mean the End of Cancer Care?

by Carol A. Westbrook

WhoKnows?You can't afford to have cancer without insurance. Medical bills from cancer run from tens of thousands to hundreds of thousands of dollars, not to mention the unreimbursed personal costs, such as loss of income, babysitting, caregiver's costs, and transportation.

Paying for this is a complex process. About 60% of peple with cancer will be 65 or older, and thus will be insured through Medicare. A few percent more will qualify for Social Security disability insurance. Some of the rest will have health insurance. The others face loss of savings, huge loans, and even bankruptcy.

But even with insurance or Medicare, many medical costs are not reimbursed–these include deductibles, co-pays for clinic visits, medical supplies, and outpatient medication. Cancer patients face especially high unreimbursed costs because their treatment may require frequent clinic visits or expensive chemotherapy pills with exorbitant co-pays.

Cancer patients and their doctors are concerned about the uncertainty of health care costs with the threatened repeal of the Affordable Care Act (ACA), or Obamacare with the new presidential administration. What will be the impact on cancer care?

In reality, the impact may be smaller than you think. Obamacare has helped with cancer care in some ways, but has made it worse in others. The most significant positive impact is guaranteeing health insurance coverage even in the face of pre-existing conditions, including cancer. Another improvement is in the ability to obtain insurance, even if you never had any in the first place. But the uninsured are still liable for the medical bills they already owe before their insurance kicks in–and they have to wait for the open enrollment period (December to January) to sign up for it through the insurance exchanges.

Where Obamacare has really failed is in cost containment. Enactment of the ACA led to rapid and often exorbitant increases in insurance premiums, or even the loss of coverage for those whose policies did not meet ACA standards. Worse yet, medical costs have continued skyrocket; there are continued increases in deductibles, co-pays, medication, medical supplies, and hospital charges. Although Obamacare does not apply to Medicare, there were collateral effects on its recipients, who faced mounting costs for their medication, for their Medicare supplemental insurance, and higher deductibles. Obamacare did nothing to stop the increase in health costs, and may have made it worse.

The other sector where Obamacare has had a negative impact is on physicians, particularly those who are in small, independent practices, unafilliated with large health-care organizations systems. These are the very doctors that serve small town, working-class or rural America. The mandate to participate in Accountable Care Organizations (ACOs) or face lower Medicare payments has forced many to close their practices, or sell them to the large health care systems.

Similarly, the mandate to implement electronic records–and show "meaningful use" by their patients, was an expense many small practices could not manage. It was particularly irrelevent in communities where few people had internet access–particularly older adults, who carry a disproportionate share of the cancer burden. It was another factor driving small doctors out of business.

Marginal communities lost their only cancer provider; other patients lost family doctors that served them for years. I know from first hand experience, as I practiced medicine in small, working-class community in rural Pennsylvania. I, for one, was not surprised that so many of my patients switched their allegiance to the presidential candidate who vowed to repeal Obamacare.

These voters are now very concerned about what will happen to their medical care when Obamacare is repealed, as President Trump promised to do. Cancer patients depend on their lives for health care. What will replace it?

Perhaps we shouldn't replace Obamacare with yet another insurance plan. Why continue a dysfunctional system in which for-profit insurance companies call the shots on the practice of medicine, while patients' costs continue to increase? Is it possible to lower health care costs, improve quality, and increase access, in some entirely different way than mandatory health insurance?

What American voters liked about Obamacare, and want to keep, is that it made health insurance available to everyone, it removed pre-existing condition exclusions, and allowed young adults to remain on their parent's policies through age 26. What people hated is that everyone was forced to purchase insurance, yet it did not lower health care costs. And it drove their doctors out of business.

The reality is that is impossible to keep these insurance features people loved without paying for them. Insurance requires that everyone contribute to the pool from which these costs are paid. You cannot have a system in insurance is purchased only when needed; medical care is expensive, and the money has to come from somewhere.

But what if health care costs were much lower, representing, say 7-9% of the GNP–as it is in most first-world countries–instead of the current 20% that we pay in the US? If that were the case, health insurance would be much more affordable, and many would sign up voluntarily, especially if it were not tied directly to employment, and did not exclude pre-existing conditions. Others would pay for their own care out of pocket.

What if drug costs were as low in the US as they are in other countries? What if we had cost transparency, so you could shop openly for the best price in tests and hospitals, regardless of state boundaries? What if large "non-profit" health care systems actually had to pay taxes on their profits? These funds could be used to subsidize care for the poor, and to help pay for cancer research and clinical trials. With lower costs it may even be possible to pay outright for routine medical care–like we used to do–purchasing insurance only for coverage of catastrophic conditions, such as cancer.

Lowering our country's medical costs would take a good administrator, someone who can negotiate like a businessman with insurance companies, pharmaceutical companies, and large health care systems. Someone who will not be influenced by lobbyists for Big Pharma, Insurance, and Mega-hospital systems. It will be interesting to see how the new administration approaches this problem.

I am hopeful that the Obamacare repeal–as inevitable as it appears to be–will mean a new beginning for cancer care.

(Reprinted in part from Ask-An-Oncologist.com, 1/10/2017 ).