ACA May Be a Tough Act to Follow

Joseph Alvarnas, MD

The Republican push to repeal the Affordable Care Act has sent anxiety levels soaring among oncologists and their patients, due largely to the great uncertainty about how exactly Congress will proceed. In addition, the replacement measures offered so far would probably result in reduced access to life-saving cancer treatment, especially for the sickest and poorest patients, according to published analyses of the plans.¹

“The general mood is one of uncertainty and some fearfulness, particularly what it’s going to mean for our patients,” said Jennie Crews, MD, president of the Association of Community Cancer Centers (ACCC). “Oncologists want to ensure that their patients continue to have affordable access to care that they need.”

Physicians and advocacy organizations say there are plenty of problems in healthcare that need fixing, such as individual insurance markets with just one or two participating payers, exchange plans with narrow provider networks and high premiums and deductibles, and low Medicaid payment rates. But the difficulty of crafting a better law has led to fears that either something worse will be approved or the ACA will simply be repealed without being replaced. “We have a lot of patients who have come here either as a result of Medicaid expansion or by being part of exchange plans,” said hematologist Joseph Alvarnas, MD, of City of Hope cancer center in Southern California. “The idea that these patients will not only lose access but may lose access to any healthcare is really dispiriting. A lot of my colleagues are very frustrated and frankly afraid of what might be coming.”

Any regulatory changes that further increase demand for drug discounts and patient financial assistance programs would represent a blow to oncology, Crews said. “Practices right now are heavily burdened, as are patients, with the financial toxicities of expensive treatments such as cancer care,” she said. “We don’t want to see that accelerated, where more resources are required and more cost is incurred by patients who might find themselves in a shortfall because of changes in the ACA that leave them without the coverage that they need.”

Republicans appear to be leaning toward a simultaneous repeal-and-replace strategy designed to prevent a sudden loss of coverage for millions of Americans, which could take a year or more to implement. However, political pressure to repeal quickly and Democrats’ unwillingness to endorse a replacement could lead to approval of a repeal schedule before a new law is in place, risking mass coverage losses. In addition, President Donald Trump could move ahead at any time with administrative actions that weaken confidence in the ACA insurance marketplaces and trigger a “death spiral” of rising premiums, falling enrollments, and payer exits from government-run exchanges, said Larry Levitt, senior vice president at the Kaiser Family Foundation, a nonprofit healthcare research organization.

Levitt said the administration could waive the individual mandate penalty for not having health insurance for large numbers of people, allowing them to drop coverage and sapping payers of revenue. It could also allow limits on certain benefits and defer the requirement that medium-sized and large employers offer their workers coverage. “They have the authority under the ACA to take a wide variety of steps that could range from blowing up the law, or scaling it back, to further stabilizing the insurance market,” Levitt said.

Trump signed an executive order immediately after his inauguration that directed agencies to waive ACA requirements to the extent permitted by law, though it has had little practical impact. The new president has promised “insurance for everybody”—including the 29 million still uninsured—and health-care that is “much less expensive and much better.”² However, none of the replacement plans analyzed by the Congressional Budget Office or independent economists would achieve those goals. A repeal bill that former President Barack Obama vetoed last year would cause 18 million people to lose coverage right away, according to the CBO, and economists estimate that if Ryan’s plan is adopted at least 4 million Americans would lose their insurance and possibly many more than that. The quality of coverage could also suffer.

The authors of several replacement proposals would try to stem such losses by subsidizing high-risk pools for nonelderly people with preexisting conditions who are uninsurable or are priced out of commercial coverage. In the past such pools included relatively small numbers of people, and expanding them to cover the 52 million adults under age 65 with preexisting conditions could prove extremely expensive for taxpayers. In addition, participants could still be burdened with high premiums and deductibles and with lifetime caps on covered services.

“It’s really an actuarial issue. How do you cover all the lives you would like to cover? You can’t do that by just having people in high-risk pools,” said Nitin Damle, MD, president of the American College of Physicians (ACP). “You need healthy people who don’t access the healthcare system as much as the chronically ill or acutely ill people do, in order to fund the insurance market. To say that everybody will be covered, that you’ll have affordable healthcare with access, and everybody’s premiums will be manageable or even lower than they are now is really a lot of pie in the sky.” He said the ACP strongly opposes repealing the ACA.

Other advocates think that proposals along the lines of high-risk pools are worth pursuing given the likelihood of repeal. Ted Okon, executive director of the Community Oncology Alliance, said he has spoken to members of Congress who are working on the problem and he believes that creating separate programs or policies for low-cost and high-cost patients could work. “Those are very different, and we tend to lump them together,” he said. “If you intelligently think through some of the ideas, and break out (coverage) segments to make sure everybody has a safety net, then you can see a way.”

Community oncology practices may be shielded somewhat from the impact of an ACA repeal because a large majority of their patients have Medicare or employer-sponsored coverage. However, many practices do have patients with exchange plans, and Medicaid is a significant payer at hospitals and cancer centers, particularly in southern states that accepted the ACA Medicaid expansion and certain other regions, Okon said.

Alvarnas, who chairs the American Society of Hematology’s committee on practice, notes that California enthusiastically embraced the ACA’s Medicaid expansion and that the state’s Medi-Cal program covers clinical trial participation. Shifting to a system of Medicaid block grants to states as some Republicans have proposed “would be very bad for us,” Alvarnas said, be- cause it would probably result in reduced funding, rationing, more pressure on charity programs, and more uncompensated care.

The ACA repeal effort has also raised concerns about the future of CMS’s Center for Medicare and Medicaid Innovation (CMMI) and the value-based payment models it manages, including the Oncology Care Model. Republicans have in the past proposed abolishing CMMI, and Damle said it could be easily defunded through a budget reconciliation bill. But Crews said she thought the organization would probably survive in some form, and Okon pointed out that a Republican-led Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which enhanced CMMI’s responsibilities.

The ACA made a number of other changes to Medicare’s finances and benefits. Pursuant to the law, the program provides free screenings for breast and colorectal cancer and other conditions, started closing the so-called doughnut hole coverage gap for Part D drug benefits, slows premium and deductible increases, and postpones the insolvency of the Part A hospital benefits fund, among other changes.³ These benefits would be lost if they are not addressed by a replacement plan.

Okon said he thought Congress might pass a repeal bill by the end of March, and Ryan has said he expected the measure to be approved in April, though it’s unclear when it would actually go into effect. Considering the difficulty of crafting an actuarially sound system of healthcare coverage, the promises Trump made, the deep political polarization in Washington, and the need for Democratic votes to pass a replacement law, it is not inconceivable that the next step of healthcare reform could take much longer than proponents predict. But Okon, who travels around the country giving talks to oncologists and practice administrators, said he’s been telling them to expect Congress to act soon. “I said, no mistake about it—they will repeal, and there will be a replacement,” he said. “In fact, there’s more pressure now on the Republicans, and there are many Republicans who believe there should not be a repeal until there’s a replacement, so they should happen fairly simultaneously.”

References

1. Kliff S. What we know about how Republicans might replace Obamacare. Vox.com. http://www.vox.com/2016/11/17/13626438/obamacare-replacement-plans-comparison. Published November 17, 2016. Accessed February 1, 2017.
2. Costa R, Goldstein A. Trump vows ‘insurance for everybody’ in Obamacare replacement plan. The Washington Post. https://www.washingtonpost.com/politics/trump-vows-insurance-for-everybody-in-obamacare-replacement-plan/2017/01/15/5f2b1e18-db5d-11e6-ad42-f3375f271c9c_story.html. Published January 15, 2017. Accessed February 1, 2017.
3. Cubanski J, Neuman T, Jacobson G, Boccuti C. What are the implications of repealing the Affordable Care Act for Medicare spending and beneficiaries? Kaiser Family Foundation. http://kff.org/health-reform/issue-brief/what-are-the-implications-of-repealing-the-affordable-care-act-for-medicare-spending-and-beneficiaries. Published December 13, 2016. Accessed February 1, 2017.

A priority for oncologists is keeping several key elements of the ACA that are especially relevant to cancer care. These include the ban on denying or charging more for insurance because of pre-existing conditions, prohibitions on annual and lifetime coverage caps, and limits on maximum out-of-pocket expenses. Another concern is maintaining good access to prevention services and screening, which lead to early treatment, better outcomes, and less spending. These principles would be weakened or eliminated in some Republican replacement proposals. For example, a number of plans, including the “Better Way for Health Care” proposed by Rep Paul Ryan (R-Wisconsin), would allow “continuous coverage” policies that charge higher premiums to cancer patients and other high-cost customers who have a lapse in coverage. Other provisions would reduce tax subsidies that help people with lower income afford insurance; allow payers to sell cheaper, skimpy plans with fewer benefits; and let payers boost premiums for older patients.