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Uneven cost control implementation for US Affordable Care Act

Published Online June 19, 2015 S1470-2045(15)00045-5 For the analysis of increased colorectal screening soon after implementation of the Affordable Care Act see Cancer 2015; published online June 4. doi/10.1002/cncr.29494/ abstract For David Howard’s analysis of narrow provider networks and insurance-exchange policies sold under the Affordable Care Act see N Engl J Med 2014; 371: 591–92 To read about possible fallout from a US Supreme Court ruling against federal subsidies for health insurance exchange policies see The New York Times http://www.nytimes. com/2015/06/11/us/affordablecare-act-insurance-premiumsubsidies.html


The 2010 US Patient Protection and Affordable Care Act (ACA) has reduced many barriers to cancer care, but cost controls have not been uniformly implemented across states, experts say. “For many people who didn’t have insurance at all, the ACA has made a tremendous difference”, says Scott Ramsey (Fred Hutchinson Cancer Center, Seattle, WA, USA). “Now people can buy into health-insurance exchanges or get employer coverage. A lot of people are newly eligible for [public insurance under] Medicaid. Those people are getting cancer care in a more timely fashion now.” One barrier the ACA sought to remove is the cost of cancer screening. A study by the American Cancer Society (ACS) found that colorectal screening prevalence improved significantly among people with low income between 2008 and 2013, after the ACA’s screening-copays prohibition. Breast cancer screening remained unchanged over the same period. Anecdotal reports suggest that the prohibition on screening copays has not been uniformly implemented across all US states, cautions Blase Polite (University of Chicago Medicine, Chicago, IL, USA). “Some patients are still facing cost-sharing because screening colonoscopy can suddenly become diagnostic colonoscopy”, says Polite. Uneven implementation was probably inevitable; the ACA provided a federal framework—and subsidies—but on-the-ground implementation was largely left to the states. Several states faced challenges in establishing online health-insurance exchange marketplaces, says David Woodmansee (ACS Cancer Action Network, Atlanta, GA, USA): “California had a heck of a problem, and several states bought technology from Connecticut because they had a real nice time with their rollout. Kentucky enrolled some of the highest percentages of eligible

people, through their exchange and Medicaid expansion. States that didn’t do real well were the usual suspects, traditionally tough on health care like Texas and southwestern US states.” The American Society of Clinical Oncology is creating an essential health benefits template to facilitate uniformity in cancer-care coverage, Polite says. “There’s a lot of concern about how well genetic screening and testing are covered by states’ essential health benefits lists”, he notes. Other problems with implementation, like high out-of-pocket costs for patients’ cancer drugs, are more systemic. “Not only are we seeing high fixed copays, but we’re also seeing highpercentage co-insurance”, Polite says. “There’s an increasing tendency for insurers to apply percentages of cost which now, with oral anticancer drugs, can reach $10 000 a month. There are out-of-pocket limits in the ACA. But even if you have a cap of $5000, if your pharmacist asks for cash on the barrel, that’s a non-starter for many patients.” High out-of-pocket expenditures partly reflect manufacturers’ price tags for on-patent anticancer drugs. At least 27 states now mandate that health insurers cover any cancer drug for any indication listed in comprehensive compendia, Ramsey notes. “That has taken away much of the negotiating power insurers have to reduce prices… Manufacturers worry their drugs will be out of date even before patents expire because so many manufacturers are moving into this space. Pembrolizumab and nivolumab have replaced ipilimumab as preferred firstline therapy for advanced melanoma— well before the patent expired on ipilimumab.” Immunotherapies are going to be even more expensive, Ramsey warns, because their manufacturing costs are among the highest in oncology. “Access versus affordability—that’s the main question about drug costs”,

Ramsey says. “Are we willing to give the insurance industry the leverage to say ‘no’ when the price is too high, or are we going to say patients have access to all cancer drugs regardless of their relative values? If we say access should be unrestricted, that’s a license to all involved in cancer therapy to disregard incremental benefits and to charge as much as they possibly can, because purchasers’ hands will be tied.” To reduce costs, many insurers are limiting cancer coverage to narrow provider networks, adds David Howard (Emory University, Atlanta, GA, USA). “Plans in the New York City area do not all cover Memorial Sloan Kettering Cancer Center, for example”, he notes. “There are examples like that throughout the country, with marketed plans not covering large-volume, highly-accredited cancer centres.” More marketplace transparency is needed, he and Woodmansee agree. “There just isn’t a lot of transparency now in terms of what insurers have to show people before they sign up for a plan”, Woodmansee says. Hawaii has just passed a bill that requires insurers to reveal out-ofpocket expenses and what drugs are covered, Woodmansee notes. A Supreme Court ruling against federal subsidies for consumers who use the federal insurance exchange, in the King versus Burwell case, could be “an absolute nightmare for patients and insurers”, predicts Polite. Millions of consumers in more than 30 states could lose federal subsidies in the case. Even if the Supreme Court leaves federal exchange subsidies in place, private insurance costs are set to increase, with insurers in several states seeking regulators’ approvals for double-digit increases in monthly premiums. “We don’t really know how much rates will go up”, Howard says. “But I do expect them to go up—probably a lot.”

Bryant Furlow Vol 16 July 2015

Uneven cost control implementation for US Affordable Care Act.

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