How will the ACA affect cancer survivors?

by Alaina Schneider

In 2010, the total cost of cancer care in the United States reached $125 billion. Globally, the economic toll from cancer is nearly 20 percent higher than the leading cause of death: heart disease. Cancer patients are also living longer today, further increasing the cost of their continued care. As the health insurance exchanges have opened and heated debate about the Affordable Care Act (ACA) continues, many questions remain, including the $125 billion question: "How will the ACA affect the most expensive disease: cancer?"

VCU Massey Cancer Center is currently examining the effects of the ACA on cancer survivors. Scientists from Massey's Cancer Prevention and Control research program are studying the ACA's impact on Medicaid-eligible populations, employment-based insurance, health benefit exchanges and safety-net providers.

The effect of Medicaid expansions on cancer screening

In 2006, Massachusetts expanded its coverage to nearly all residents of the state, becoming the policy template for the ACA, which will expand Medicaid coverage in many states. Massey researcher Lindsay Sabik, Ph.D., led a team to examine how cancer screening changed before and after Massachusetts' health care reform. She found that, overall, the reform appeared to have increased breast and cervical cancer screening, particularly among low-income women, suggesting a positive effect of near-universal coverage on preventive care.

 "Preventive care is very important," said Sabik, principal investigator of the study. "Studies have shown that with the right approaches a third of the most common cancers could be prevented. After seeing the impact of health reform on cancer screening in Massachusetts, we are interested in seeing if the insurance coverage expansions will have similar effects in other states."

Sabik and her team are currently funded by the National Cancer Institute (NCI) to research how state Medicaid policies are impacting breast and cervical among low-income women around the country. "The results," she said, "will help us develop strategies to reach the under-screened populations, which is critical for health care providers in reducing inequalities in cancer care and outcomes across socioeconomic and racial groups."

The ACA's impact on the working cancer survivor

Cancer patients often experience fear of losing their health insurance if they cannot continue to work after diagnosis. Cathy Bradley, Ph.D., co-leader of the Cancer Prevention and Control research program at Massey, has focused her studies on the implications of the ACA on Americans dependent on employer-sponsored health insurance after experiencing a health shock, such as cancer.

Bradley studied employed married women newly diagnosed with breast cancer and compared the hours worked between those who were dependent on their own employment for health insurance and those who had access to their spouse's insurance.

"Our findings show that breast cancer survivors who are dependent on employer-sponsored health insurance had a greater incentive to uphold a higher labor supply in order to maintain access to coverage. But with the ACA, cancer patients will no longer have to worry about losing their health insurance if they can no longer work," said Bradley, principal investigator of the NCI-funded study.

"The law will give patients access to outside of the employer-based system, which will have a positive impact on the working cancer survivor."

And although Bradley said that having private health insurance outside of the workplace will not incentivize to stop working, if they do choose to stop working or if they have to, it will allow them to devote their time to treatment and recovery.

Consumer ability to understand the ACA's health insurance exchanges

Since the ACA health insurance exchanges opened, many Americans have reported experiencing difficulty  selecting the best insurance plan for them. Massey researcher Andrew Barnes, Ph.D., is currently leading a study that investigates the ACA's Health Insurance Marketplace.

Barnes said, "The exchanges rely heavily on consumers' ability to process, comprehend and compare a vast amount of information on numerous insurance plans to make important choices."

He has identified factors that may become a challenge for consumers in working with the exchanges, such as the consumer's perceived risk, their comprehension of their insurance terms and plan features and their health literacy.

"Preliminary data from our experiments using mock exchanges suggests approximately 50 percent of uninsured participants are purchasing health insurance in the experiments that, given their health status and utilization history, do not offer adequate coverage," Barnes said.

Barnes has also found that not only patients but doctors are having trouble navigating the exchanges. In another study, he asked 70 medical students and residents to choose the cheapest Medicare plan for a hypothetical patient, "Bill," from a list of three or nine plans. When given three options, two-thirds of the students and residents chose the right policy for Bill, but when given nine options, only one-third chose correctly.

"Our results reinforce the notion of 'choice overload,' where the more options we have, the more difficulty we have processing and comparing the attributes of these options and making a decision," Barnes said.

The ACA's impact on safety-net hospitals

The impact the ACA will have on safety-net providers is another important question being studied. Safety-net providers, such as Massey, deliver a significant level of health care and other health-related services to the uninsured that they cannot receive elsewhere. In fact, our researchers have found that uninsured and Medicaid patients in Virginia have lower surgical mortality in safety-net hospitals than non-safety-net hospitals.

Safety-net providers receive disproportionate share hospital (DSH) funding, which offsets the cost of care to uninsured patients and mitigates the underpayments by Medicaid. The ACA reduces DSH funding for safety-net providers because many uninsured people will now be insured through the ACA. But the increase in coverage among uninsured patients will be smaller than initially anticipated in states that don't expand Medicaid.

"Although the ACA will expand to many who are currently uninsured, there will still be uninsured people remaining," said Sabik, principal investigator on the study. "The ACA will take away subsidies that offer support to safety-net hospitals that provide medical care to those left uninsured. Financial support will be needed for these institutions following the implementation of the ACA in order for them to continue to afford to provide care for those remaining uninsured."

Future studies and continued efforts

Overall, Massey's research has found that the ACA will have a positive impact on patients by allowing for increased lifesaving preventive care and the option to take time off work to focus on cancer treatment and recovery without fear of losing health insurance. But the research also concluded that the "choice overload" of health insurance exchange options can be confusing and hard to understand for both patients and doctors, and although the ACA will reduce the number of uninsured, it will also lessen the support of safety net providers and, therefore, the care they can afford to provide to those patients who remain uninsured.

As the ACA is implemented further, Massey researchers will continue studying and reporting on the full impact of the ACA on survivors and providers.

More information: Lindsay M. Sabik and Cathy J. Bradley. "Differences in Mortality for Surgical Cancer Patients by Insurance and Hospital Safety Net Status." Med Care Res Rev 1077558712458158, first published on September 4, 2012 DOI: 10.1177/1077558712458158

Barnes AJ, Hanoch Y, Martynenko M, Wood S, Rice T, et al. (2013) "Physician Trainees' Decision Making and Information Processing: Choice Size and Medicare Part D." PLoS ONE 8(10): e77096. DOI: 10.1371/journal.pone.0077096

Cathy J. Bradley, David Neumark, Scott Barkowski, "Does employer-provided health insurance constrain labor supply adjustments to health shocks? New evidence on women diagnosed with breast cancer," Journal of Health Economics, Volume 32, Issue 5, September 2013, Pages 833-849, ISSN 0167-6296, dx.doi.org/10.1016/j.jhealeco.2013.06.008.

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