Can We Hope for the Best From the Affordable Care Act?

Andre Goy, MD, MS

Editor-in-Chief of Oncology & Biotech News

Chairman and Director Chief of Lymphoma Director, Clinical and Translational Cancer Research John Theurer Cancer Center at Hackensack University Medical Center

The classic saying Have a Happy and Healthy New Year takes a particularly important meaning this year, as Jan 1, 2014, is now a landmark date in the history of US healthcare with the implementation of the Affordable Care Act (ACA), also referred to as Obamacare, which was passed into law in March 2010.

Almost 50 years have passed since the last big change in US healthcare came with the establishment of Medicare in 1965. However, the complexity and scope of the ACA is truly unprecedented given both the number of players (patients, physicians, hospitals, pharmacies, pharmaceutical industry, diagnostic companies, employers, and insurance providers) and the extensive medical progress since the implementation of Medicare, which has translated into much more complex and costly medical care.

The ACA was enacted with the goals of increasing the quality and affordability of health insurance. The law requires coverage through either an employer, Medicare, expansion of Medicaid (younger adults), or through personal mandate (or else financial penalty). It also requires minimum standards for health insurance policies and increases coverage: no coverage denial for preexisting conditions, no lifetime cap, no/lower copay for screening and preventive medicine, and children up to age 26 can be included under their parents’ coverage. The ACA will mostly be financed by increased taxes and decreased Medicare reimbursement to hospitals.

Despite more than 3 years of preparation since the law passed (with numerous attempts to repeal it) and putting politics aside, the reality of implementation of the ACA is and will be—as expected—facing numerous serious challenges. Appropriate concerns have emerged over the last few months, including difficulties for individuals trying to sign up (horrendous ACA website stories), challenges in the insurance exchanges from increased premiums, the inability to keep one’s previous plan, and forced loss of access to individuals’ existing healthcare providers. Meanwhile, the controversy about the reluctance of some states to even support Medicaid expansion adds to the growing anxiety.

Although to this day only a minority of Americans—much fewer than predicted—have signed on for new health plan coverage, it remains totally unclear in this transition phase how things will unfold practically. A number of justified concerns persist on how this is going to translate into doctors’ offices, from confusion about coverage, increased premiums and/or deductibles, to increased medical spending, and eventually poorer coverage and worsening of quality of care.

That being said, no one would (or could) deny that the current course of spending for healthcare in the United States is not sustainable. The Medicare Sustainable Growth Rate (SGR) is currently used by the Centers for Medicare and Medicaid Services to frame federal healthcare spending. Generally, this method aims to ensure that the yearly increase in the expense per Medicare beneficiary does not exceed the growth in gross domestic product. Though it is necessary to control healthcare costs, adjustments of SGR (hence, of reimbursement to physicians) occurred for many years solely through temporary remedies, keeping physicians and patients in a constant state of uncertainty, and this is also not sustainable.

At the end of 2013, the government issued a new temporary relief with a 3-month, 0.5% payment increase (the first since 2010) in lieu of the 24% cut in Medicare reimbursement initially scheduled for January 2014. A reliable payment system will be essential to support the enforcement of all these changes at a time when physicians are already facing pressure related to the electronic health record mandate and the upcoming new ICD- 10 coding implementation, on top of the uncertainties related to the ACA itself.

Amid all these controversies and growing concerns, public support for the law has dropped to a record low and is the subject of intense politics. I believe, however, that it is important that we do not lose track of the main goal, which is improving the health of all Americans.

Given the stakes, one should view this as an opportunity for greater and more commendable changes by focusing more on quality, outcome, and accountability, instead of just the possibility of rationed care though an increasingly complex and cumbersome regulatory and bureaucratic environment.

Being an oncologist, it appears rather obvious to me that cancer provides a perfect platform to develop a new and requisite model that could be an example of a move toward transformative care in medicine. A number of converging forces are undeniably reshaping oncology: costly medicine (with the bulk of expenses still spent in the palliative setting), an aging population (increasing cancer incidence), and better outcomes due to better therapies. Further, the molecular diversity of cancer will affect drug development and clinical trial design (targeting patient populations based on molecular rationale), which in turn could reduce the cost of drug development and hopefully the eventual cost of the drugs. Together with the availability of high-throughput diagnostic technologies (sequencing and other genomics approaches), a natural shift toward personalized or precision medicine in oncology is palpable and has already started.

More than ever, it will be particularly important in oncology to all work together to bring innovation and novel therapies to patients. The ACA needs to address the issues related to clinical trial support and access for patients while easing the burden of investigators subjected to an increasingly cumbersome regulatory environment. The enormously complex ACA has already been amended multiple times and is likely “not final”; let’s hope appropriate changes can and will be made to support innovation and continued progress, as knowledge remains the best medicine.

Meanwhile, proactively involving physicians in responsible initiatives to control cost and improve outcomes appears more constructive and promising. Moving toward bundled care with relevant patients’ stratification and innovation is the future. The answer is to view this as an opportunity to be transformative in oncology and medicine at large: Would anyone not want rationale care versus coercively rationed care?

Change of this scale is never easy, but with the well-being of our society at stake, as well as the future of medicine and innovation leadership in our country, the ACA needs to address, support, and embrace all the exciting changes happening in cancer care and medicine as a whole.

It’s a new dawn…Have a Happy and Healthy New Year.