Federal Healthcare Policy Is Front and Center at CANCERSCAPE Conference

Kavita Patel, MD, MS

The steep $5.8 billion cut in spending for the National Institutes of Health proposed by President Donald Trump is just an opening gambit in the long negotiations ahead over the 2018 federal budget, said Kavita Patel, MD, MS, a policy analyst with The Brookings Institution who was one of the keynote speakers at the annual CANCERSCAPE meeting of the Association of Community Cancer Centers this week.

In an interview with OncLive®, Patel provided an overview of the Capitol Hill scene as the Trump administration’s first year unfolds with a dramatic attempt to revise healthcare policy. Patel also discussed the potential for a resurgence in the Republican effort to repeal the Affordable Care Act (ACA) and the impact of legislative reform and revision on physicians and patients.

Currently a fellow at the Brookings Institute, Patel previously served as the director of policy for the Office of Intergovernmental Affairs and Public Engagement under former President Barack Obama. Prior to that time, she was deputy staff director for health under the late Sen Edward M. Kennedy.

OncLive®: What do you see happening as legislators continue to battle over the Affordable Care Act (ACA)?

Patel: The American Health Care Act (AHCA) [the Republican answer to the ACA] has potentially resurfaced with some comments by House Speaker Paul Ryan and President Donald Trump that they are still going to do something on health care repeal. It's a low likelihood, but there could potentially still be some action or activity around repeal through the budget reconciliation process, which allows them several months to act.

Otherwise, it's now going to be important to have Democrats come out, even just symbolically, with some version of an ACA fix, so it can look as if the things that people are criticizing the ACA for will get solved in some way. A White House with a Republican in it is very unlikely to sign something to improve Obamacare, but that's what I think the next several months will produce. It will be very political, and I don't know how much how much change we’ll see in the healthcare plan. I think we're still going to see the ACA as the law of the land for, honestly, not just the "foreseeable future," which is what Paul Ryan predicted, but probably for the rest of this administration, unless there is a dramatic political shift.

Are you a proponent for removing the individual mandate penalty for not buying insurance under the ACA?

Actually, I think the individual mandate needs to be stronger—there needs to be more of a penalty to not purchase insurance.

There also need to be regulations that transform the federal marketplace into something like California has, where they actively manage the benefits—it’s called an active exchange model. The federal marketplace is not an active model. The exchange doesn't actively say, “We want everyone to get free primary care,” or “We want for everyone to get free preventive care,” even though these things are possible through the ACA.

The third thing is the age rating. Right now, there's a certain limit on how much payers can charge based on someone's age. I think that probably needs to get widened. If that were to happen, it may become a little more expensive for older people to buy healthcare, unfortunately. But I think that's one solution—not to make it attractive, but to make it probably more affordable for younger, healthy people—which is really what we need to make more people buy healthcare.

What do you see happening with the president’s 2018 budget proposal? Do you think we'll see the cuts that are laid out there, particularly to the National Institutes of Health (NIH)?

Every time a president, especially a first-term president, releases their budget, it's more symbolic than real. But, if Congress wants to increase defense spending or increase certain areas of spending, they're going to have to cut from other areas. Unfortunately, I do think we're going to see some very lean times. Maybe not exactly how President Trump proposed, but I think we're going to see some lean times for organizations like the NIH, the Centers for Disease Control, and other agencies for healthcare research and quality—organizations that have important roles in healthcare. I think it's going to be hard to see increases in those budgets.

Where do the budget situation and the healthcare environment leave patients and providers?

Everybody involved in clinical care is left a little bit confused. For a long time, people were wondering if the ACA was going to pass, then they were wondering if the Supreme Court was going to strike it down. Recently, as late as last week, we were wondering if the AHCA would replace the ACA. Just when doctors are getting ready to do something in response to the ACA, they're getting signals of "Wait a minute! This is going to go away. You don't have to do this anymore."

A lot of patients are worried about whether Medicare is going to be an insurance program that can give them what they need, and I think that's a valid concern. The way we spend money in Medicare is becoming much more costly. Even though the last couple years have seen very modest growth in the Medicare program in terms of cost, there are now projections that it's going to become much more expensive. I think patients are wondering, “Is Medicare going to take care of what I need?” “How will I afford insurance as I get older?” Those are all pretty important concerns. Certainly, I worry about it myself.

I expect that the cost of healthcare, unless we do something really different, is going to continue to rise.

Within the ACA, what provisions and measures are relevant to oncology professionals?

CMS put into place accountable care organizations and the Center for Medicare & Medicaid Innovation. Those are all things that changed the way oncologists are getting paid for care. They're also changing the conversations oncologists are having with patients about cost. A lot of these programs are asking doctors to talk to patients about cost. That's a very different model than we had 10 years ago.

What should we be paying attention to in the coming months?

The big action might be around the FDA and some of the things that are happening right now with reauthorization. For example, the Children's Health Insurance Program has to be reauthorized this year or it expires. There will probably be some negotiations around that. That's an opportunity for a drug pricing conversation.