study whether it is possible to move patients to existing facilities, rather than building more. It makes more sense to move the patient to machine than the machine to the patient. I am always surprised by the complaint of health-care systems, that they cannot transport patients where they need to go, but there is no place in the world where you cannot get a cold beer or carbonated drink. Do we value the transport of beer or soft drinks more than sick people? Fourth, one could simply wait. When I was a college student, a pocket calculator that did addition and subtraction cost US$500. The odds are high that, with time, the pricing bubble for particle therapy will collapse. Finally, the problem of graduate medical education could be solved, at least partly, with technology. We should strive to supplement clinical instruction and textbooks with online courses. One should also consider cross-border residency education. Cancer in children and adolescents accounts for 1·4% of all cancers worldwide, but 4·8% of cancer in Africa— mainly because of diﬀerences in age composition and life expectancy. 94% of all deaths from cancer in people aged up to 14 years are in countries of low and middle income.10 Because most of the paediatric cancer burden is in low and middle income countries, these are the best locations to train residents in paediatric radiation oncology. However, the more we, as a specialty, promote the use of more complex radiation therapy machines, the more we will restrict the access of middle and low income countries to any form of external-beam
radiation therapy. Equipment manufacturers will have no incentive to engineer, manufacture, and sell simple low-cost machines. All radiation oncologists have a part to play in solving the existential problems facing the specialty, no matter who or what caused these problems. As AJ Heschel taught, few are guilty, but all are responsible. Edward C Halperin New York Medical College, Valhalla, NY 10595, USA [email protected]
I declare that I have no conﬂicts of interest. 1
2 3 4 5
6 7 8
Accreditation Council For Graduate Medical Education. Program requirements for graduate medical education in radiation oncology, 2009. http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ ProgramRequirements/140_EIP_PR205.pdf (accessed Nov 5, 2013). Brotherton SE, Etzel SI. Graduate medical education, 2011–2012. JAMA 2012; 308: 2264–79. Baumol WJ, Bowen WG. On the performing arts: the anatomy of their economic problems. Am Econ Rev 1965; 55: 495–502. Retlig RA, Jacobson PD, Farguhar CM, Aubry WM. False hope: bone marrow transplantation for breast cancer. Oxford: Oxford University Press, 2007. Chow E, Hahn CA, Lutz ST. Global reluctance to practice evidence-based medicine continues in the treatment of uncomplicated, painful bone metostaces despite level 1 evidence and practice guidelines. Int J Rad Oncol Biol Phys 2012; 83: 01–02. Giordano SH. Radiotherapy in older women with low-risk breast cancer: why did practice not change? J Clin Oncol 2012; 30: 1577–78. Welch HG. Testing what we think we know. New York Times (NY). Aug 19, 2012: A19. Bekelman JR, Brawley OW, Densy Jo, et al. A research agenda for radiation oncology: results of the radiation oncology institute’s comprehensive research needs assessment. Int J Rad Oncol Biol Phys 2012; 84: 318–22. Bogdanich W. The radiation boom: Radiation oﬀers new cures, and ways to do harm. New York Times (NY). Jan 23, 2010. Magrath I, Steliarova-Foucher E, Epelman S, et al. Paediatric cancer in low-income and middle-income countries. Lancet Oncol 2013; 14: 104–16.
Should oncologists support the Aﬀordable Care Act?
B Boissonnet/Bsip/Science Photo Library
The Aﬀordable Care Act (ACA) or ObamaCare is today the law of the land in the USA. However, attempts continue to reverse, defund, or slow down its implementation based on ideological convictions. Most Americans do not know what it provides, so clariﬁcation of its simple premises would be helpful. Some beneﬁts of the ACA are: ﬁrst, 30 million of the 50 million uninsured US citizens will gain insurance coverage; second, children can remain on their parents’ insurance, if they wish, up to the age of 26 years; third, insurance companies cannot deny coverage for pre-existing medical disorders, or cancel insurance if someone gets sick, they also cannot cap the amount of care received in a patient’s lifetime, or deny coverage 1258
on clinical trials; fourth, the cost of care is reduced and money is saved on medications for senior citizens on Medicare (gradual closing of the part D coverage gap, known as the donut hole, which forces patients to pay for out-of-pocket drug costs after a certain ﬁnancial threshold is reached); ﬁfth, insurance companies must spend 80–85% of collected insurance funds on health care (this value was as low as 50–60%).1 The ACA oﬀers comprehensive coverage for private health care, increases choice of cover, does not create a single-payer system, and does not reduce quality of care. It does not force individuals to change insurance, as long as the policy complies with the ACA requirements to include basic beneﬁts and to exclude exorbitant www.thelancet.com/oncology Vol 14 December 2013
deductibles. Insurance premiums could decrease on average by 10–18%,2 depending on the state support of the health plan and its establishment of health-care exchanges. While upholding the ACA constitutionality, the Supreme Court allowed states to reject the federally funded expansion of Medicaid.3 This unfortunately makes ACA’s implementation diﬃcult. In simple terms, the US Government will provide health-care support equivalent to about US$1 trillion (over 8 years from 2013 to 2022) to states that accept the Medicaid expansion. The Federal Government provides about $952 billion of these expenses; all states provide about $76 billion.4 Full expansion of Medicaid decreases yearly deaths by about 90 000.5,6 The unwillingness to expand Medicaid coverage disproportionately aﬀects vulnerable groups, including two-thirds of poor black people and single mothers, and more than half of low-income workers who did not have coverage before the ACA law was enacted. It has been argued that patients on Medicaid might have a worse outcome than patients with private insurance, Medicare, or no insurance. Patients on Medicaid are poor and have economic hardships that could prevent compliance with optimum care (out of pocket costs, travel, inability to take time oﬀ work, childcare issues). However, research conﬁrms that Medicaid coverage improves outcome and reduces mortality compared with no insurance.6 How does the ACA aﬀect oncology care speciﬁcally? First, because ACA extends cancer care to 30 million individuals and expands Medicaid, more patients with cancer will be covered, thus eliminating today’s ethical dilemmas of how to help these patients. Second, cancer survivors cannot be denied insurance for their preexisting or ongoing disorders (treated cancer, therapyrelated new cancers or diseases). Third, it closes the hole in Medicare Part B that forces older patients with cancer to pay high out-of-pocket costs for increasingly more common and also very expensive oral cancer drugs. Fourth, coverage cannot be rescinded on the basis of so-called technicalities (sometimes used by insurance companies to deny expensive care). Fifth, patients will be covered for cancer clinical trials (arguably the best approach to cancer therapy nowadays). Sixth, there will
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be no upper limit on yearly coverage of cancer care for the patient’s lifetime. On the other hand, there is fear that rationing cancer care based on cost beneﬁts, bundling payments for episodes of care (rather than fee-for-service), restricting cancer care pathways, and tightening evidence-based care—which reduce cost—will also restrict therapeutic options and reduce oncologists’ revenues. Although oncologists might worry about loss of income with the implementation of the ACA, medicine is about what is best for our patients, and honouring our Hippocratic Oath to protect patients from harm and injustice. Consider the moral dilemma oncologists face daily when a patient with cancer is uninsured or has insurance that restricts care. The ACA oﬀers oncologists the peace of mind that they can deliver the best care available without worries about compromises related to economics. The ACA has many ﬂaws, but it is better than what was. As it is implemented, its unintended ill-eﬀects can be remedied with further legislation, as was done with Social Security and Medicare. Oncologists should advocate for the ACA and work on improving it. *Hagop Kantarjian, David Steensma, Donald Light Leukemia Department, The University of Texas MD Anderson Cancer Center, 1400 Holcombe, Houston, TX 77030, USA (HK); Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02215, USA (DS); and Harvard University, Edmond J Safra Center for Ethics, Cambridge, MA 02138, USA (DL) [email protected]
We declare that we have no conﬂicts of interest. 1
Sebelius K. More value for your dollar. April 27, 2012. http://www.hhs.gov/ healthcare/facts/blog/2010/11/medical-loss-ratio.html (accessed Nov 12, 2013). Clark P. Insurance rates on ObamaCare exchanges: good news (and caveats). Bloomberg Business Week (NY). Aug 12, 2013. http://www. businessweek.com/articles/2013-08-12/insurance-rates-on-ObamaCareexchanges-good-news-and-caveats (accessed Nov 12, 2013). Supreme Court Center on Budget and Policy Priorities. Status of the ACA Medicaid expansion after supreme court ruling. Sept 4, 2013. http://www. cbpp.org/ﬁles/status-of-the-ACA-medicaid-expansion-after-supremecourt-ruling.pdf (accessed Nov 12, 2013). Perkins J. 50 reasons Medicaid expansion is good for your state. National Health Law Program. Aug 2, 2012. http://consumersforhealthcare.org/ sites/default/ﬁles/50_reasons.pdf (accessed Nov 12, 2013). Price CC, Eibner C. For states that opt out of Medicaid expansion: 3·6 million fewer insured and $8·4 billion less in federal payments. Health Aﬀ (Millwood) 2013; 32: 1030–36. Sommers BD, Baicker K, Epstein AM. Mortality and access to care among adults after state Medicaid expansions. New Engl J Med 2012; 367: 1025–34.