Dec 6, 2019
Dr. Nate Pennell talks with Dr. Joel Segel about “Coverage, Financial Burden, and the Affordable Care Act for Cancer Patients.”
Article available online at Journal of Oncology Practice.
TRANSCRIPT
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[MUSIC PLAYING]
Welcome to the latest Journal of Oncology Practice
podcast, brought to you by the ASCO Podcast Network, a collection
of nine programs covering a range of educational and scientific
content, and offering enriching insight into the world of cancer
care. You can find all recordings, including this one, at
podcast.asco.org.
My name is Dr. Nate Pennell, medical oncologist at the Cleveland
Clinic and consultant editor at the JOP.
Medical care can be very expensive in the United States. And a
diagnosis of cancer can be a huge shock, both physically, mentally
and financially. Medical expenses don't just impact financial
lives, but may also impact treatment outcomes, as even patients who
are cured of their cancer may be left with a significant amount of
debt.
One of the primary goals of the Affordable Care Act-- so-called
Obamacare-- was to increase the number of citizens covered by
health insurance, so that these financial burdens would be
lessened. And we know that as the result of the Affordable Care
Act, overall insurance coverage did increase. But how well did this
work for patients with cancer specifically? And what impact has it
had on financial burdens?
With me today to discuss these issues is Dr. Joel Segel, assistant
professor of health policy and administration at the Penn State
University. We'll be discussing his paper, Coverage, Financial
Burden, and the Affordable Care Act for Cancer Patients, to be
published in the October 2019 JOP. Welcome Dr. Segel. And
thanks for joining me today.
Thank you for having me.
So can you start, for our audience, just by putting the general
landscape into perspective for us. What are the financial burdens
that cancer patients go through, especially those who are in lower
incomes?
Sure. So there's certainly been a lot of evidence that cancer
patients face, obviously, a number of medical care and health
burdens, but also financial burdens. And in some cases, the
financial burden can be pretty significant.
We also know that certain groups are probably disproportionately
affected. So we know lower income, especially sort of racial and
ethnic minorities, and especially some of the younger cancer
patients can face significant financial burdens, but it also varies
quite a bit. And so the evidence is certainly mixed in terms of how
it's measured, how a financial burden is experienced by these
different patients, but it can be as extreme that there is evidence
that 2% to 3% can experience financial bankruptcy. So these can be
pretty significant financial burdens.
And I guess the last thing would be there's probably two ways in
which a patient can face a significant financial burden. So one is,
and the one that we actually focus on most in our paper will be,
the financial burden that results from medical care costs. We can
also think about that, obviously, cancer can affect an individual's
ability to work. So there can also be an additional financial
burden if they're unable to work or they have to cut back on their
hours, and that leads to a reduction in their income.
And is there evidence that patients' insurance status factors into
their financial strain and burden?
Yes, there's certainly evidence that patients that have more
comprehensive coverage, especially those that are higher income,
that may help to mitigate much of the financial burden, whereas
patients-- and that's one reason why younger patients sometimes
have less comprehensive coverage. And they also may have less in
savings and be less prepared to deal with some of the financial
burdens.
And I think that makes perfect sense. And so what was in the
Affordable Care Act that was designed to help patients deal with
this?
The Affordable Care Act is an extensive law with a whole bunch of
different features. I think there are several that are probably
particularly relevant for cancer patients. So one is the one that's
probably talked about a lot, which is the Medicaid Expansion. So
initially, states were required to expand Medicaid. Due to a
Supreme Court case, it became optional. So certain states decided
to expand Medicaid, and that meant that they expanded who would be
eligible. So primarily lower income adults, particularly ones
without children, became eligible for Medicaid in certain states.
So that's one piece.
I think the other one that's come up a lot, especially in a lot of
the news stories, would be the restrictions on preexisting
conditions. So certainly leading up to the Affordable Care Act, one
major concern was that individuals, particularly-- cancer was one
of the prominent examples would be if they had previously been
diagnosed with cancer, they might have trouble either obtaining
health insurance coverage or being renewed for health insurance
coverage. So the Affordable Care Act made it so that regardless of
what health care conditions an individual had, they were guaranteed
renewability of the health insurance or the ability to purchase a
health insurance plan.
And I think the last two general sections that might also affect
cancer patients would be, one, they set up a number of state-based
health insurance exchanges to allow individuals to purchase health
insurance, and particularly for individuals who are buying
individual plans and not through their employer, prior to the
Affordable Care Act, especially for those with cancer, might have
had difficulty purchasing a health insurance plan. So these
state-based exchanges were an opportunity for individuals to
purchase health insurance, and depending on their income with
subsidies. So there were both subsidies for the premiums, or what
an individual would pay each month for their health insurance plan,
as well as cost-sharing subsidies. So for lower income individuals,
they could become eligible for additional assistance to help cover
some of their medical care costs.
And then, I guess, the last part would be that the Affordable Care
Act placed limits on what an individual would have to pay out of
pocket, both in terms of within a given year, and also, they got
rid of some of the lifetime limits to health insurance.
OK. So it's obviously a complex law with a lot going on. But
fundamentally, ultimately, the hope was that more people would be
insured and that fewer people would suffer the consequences of
having to pay for expensive medical care without having the
insurance to help them with that.
So with that now put into perspective, take us through your study.
How did you design this? And what were you hoping to look for?
So what we wanted to do was to take a look at, in particular, the
non-elderly population who had been diagnosed with cancer. So what
we did is we took a look at a large nationally representative data
set, the Medical Expenditure Panel Survey, which follows a random
sample of individuals across the United States for a period of two
years. And within that, we then try to identify a non-elderly-- and
by non-elderly, that'd be ages 18 to 64-- who had been previously
diagnosed with cancer, or who, in the data, we could observe that
they had some utilization for which there was a diagnosis of
cancer.
And we then further restricted it, for much of our sample, to the
lower income population. So that would be individuals who lived in
a family that was at less than 400% of the federal poverty level. I
guess to give a bit of a sense of that, that would be about $48,000
for an individual or $100,000 for a family of four currently. And
we specifically chose that threshold, because that's the threshold
by which individuals qualify for premium subsidies on the
state-based exchange.
In particular, what we're going to look at is, first, we're going
to look at coverage, so the number of months an individual spent
either uninsured with Medicaid coverage or with private coverage.
Among those with private coverage, we also took a look at whether
they were enrolled in a high deductible health plan. We also looked
at spending in terms of both their overall spending and also their
out of pocket spending. And then, finally, to get a better sense of
some of the financial burdens that families might face, we looked
at both the change in what this family had to pay out of pocket for
their health insurance premiums, so just the part that the family
or individual pays as well as the fraction that a family pays for
their health care costs, and that would be both the medical costs
as well as the out of pocket premium.
And our last one, in addition to the fraction of income spent,
would be whether they crossed a threshold of 20% of their family
income spent on health care costs, which is a commonly used measure
of high medical burden.
OK. So I think that makes sense focusing on that group. So what did
you find?
So we look at a couple of different samples, both the lower income
cancer population as well as the higher income cancer population.
And we look at sort of how those outcomes changed from before the
Affordable Care Act to after the Affordable Care Act. And in
addition, we were going to make some comparisons to try to get a
better sense of whether these changes looked different for
different groups, so whether the higher income cancer group, how do
they compare to the lower income cancer group, how the different
cancer groups might compare to a population with a similar income
level, but without cancer.
Similar to other studies, we see a significant improvement in
health insurance coverage among the low income or the lower income
sample with cancer. We find that that's driven largely by both an
increase in Medicaid coverage as well as an increase in the high
deductible health plans. So people seem to be enrolling in either
Medicaid or private coverage, and that tends to be with some of the
higher deductible health care plans. We see similar changes for
individuals who what we'll call current cancer, and those are the
ones who not only have been diagnosed with cancer, but show some
utilization in the current year.
And then, I guess, in addition, what we find, we find something
slightly different in the higher income cancer sample, and that's
that they also experience an increase in the enrollment in high
deductible health plans, but they also see a significant increase
in their out of pocket premiums as well as the fraction of family
income spent on health care. And so that's what we see in terms of
just comparing pre and post. But we also do a number of comparison
to some different groups to try to tease out sort of what might be
driving, and sort of how similar the cancer population might look
in terms of their improvements to some of the other population.
You mentioned that a lot of this had to do with the expansion of
Medicaid, but of course, that that was rather sporadic because not
every state expanded Medicaid. Did you look regionally at these
numbers or is this basically nationwide?
So it's nationwide. In some of our adjusted analyses, we're able to
control for region. But actually, one of the limitations of our
study is that in the data that we have available, we can't identify
an individual's state. So we don't know whether or not they're
necessarily in an expansion state or a non-expansion state.
Yeah, because one of the first things that occurs to me is that if
everyone had expanded, would the number be larger? And is there any
evidence of the Affordable Care Act improving coverage and
financial burdens specifically in states that didn't expand
Medicaid? But I think that would be an interesting thing to look at
maybe in the future.
Absolutely, and there's certainly some evidence to suggest that
within cancer populations, generally, there does seem to be
improved health insurance coverage, in particular, in some of the
Medicaid Expansion states precisely for the reasons that, I think,
you're mentioning.
One of the other things you looked at is you looked at a comparison
group with a higher income level, what did you find in that group
sure so one of the comparisons we make is that some changes in our
outcomes between the lower income cancer sample and the higher
income cancer sample what we see is maybe not surprisingly there's
less of a change in health insurance coverage among the higher
income cancer sample part of that is that they've had they had
higher coverage rates to begin with. But what we also see is an
increase in the out-of-pocket premium of about $800 per year for
the higher income sample relative to the lower income sample. And
we also see it relative to lower income sample that day they
experience about a two to three percentage point increase in the
fraction of their income spent on health care costs. What we find
seems to be driving that is actually
more of a modest increase in the fraction spent among the higher
income cancer sample along with sort of a very modest decrease in
the lower income sample where are you going to go from here with
these data what future studies do you have planned and what ideas
can you pull from this to try to help reduce future financial
burdens on cancer patients. So part of it is trying to get access
to some of the restricted data where we would actually be able to
identify what state people are and so we could get a much better
sense of whether we're seeing some of these changes differentially
in expansion states versus non-expansion states.
Also, with some additional restricted data, we'd able to get a
better sense of how these patients might be transitioning across
different types of health insurance plans once they're diagnosed
with cancer. So right now, we've got a mix in terms of patients who
are in active treatment and more recently diagnosed, along with
patients who may have been diagnosed further back. I mean,
unfortunately, in the data we currently had, we're not able to
accurately distinguish exactly when they were diagnosed. But again,
we'd be able to better tease out some of those differences between
people who had maybe been diagnosed longer ago versus more
recently.
So one of the things that everyone is worried about today, of
course, is the rapidly rising cost of medical care, especially
drugs in patients with cancer. That probably poses a challenge to
doing this kind of research showing pre and post expenses when the
actual cost of care is going up during the study period.
It's certainly an important thing to consider. Obviously, during
this time period, the cost of, in particular, some of the cancer
therapies has gone up significantly. We try to account for it, I
guess, in a couple of different ways. One was going to be we're
comparing some of the higher income and the lower income
populations to get a sense of whether they differentially
experience some of the financial burden. So to the extent that both
lower income and higher income cancer patients are facing the same
increase in drug prices, we would control for that to some
extent.
I guess the other comparison we made was to compare, in particular,
the lower income cancer sample to a lower income sample that did
not have cancer. And actually, interestingly, what we find is we
don't really find much of a significant difference between those
two samples. So what that suggests is that the Affordable Care Act
improves coverage and may help to mitigate some of the financial
burden, but it does similarly for both cancer and non-cancer
patients who are low income.
And that makes sense. As much as we pay attention to cancer because
that's our field, it's only one of major health issues. Especially
in a non-Medicare age population, I would think there'd be a lot of
other competing risks. But still, it sounds like that is a good
control over the overall rising costs of health care.
Well, Dr. Segel, thanks so much for joining me for the podcast
today.
Thank you for having me.
Until next time, thank our listeners as well for listening to the
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2019. This is Dr. Nate Pennell for the Journal of Oncology
Practice signing off.