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Affordable Care Act: It’s All in the Details … and There Are No Details

Ted Bosworth, Clinical Oncology News

Chicago—With several key provisions of the Affordable Care Act (ACA) set to take effect on Jan. 1, it is still difficult to predict exactly how it will affect the treatment of cancer, a panel of policy experts told oncologists at the 2013 annual meeting of the American Society of Clinical Oncology (ASCO).

The 900-page act, colloquially known as Obamacare, is dauntingly complex, yet very little deals specifically with cancer care.

“There are really very few oncology-specific components,” said William C. Penley, MD, a medical oncologist at Tennessee Oncology in Nashville, who has served on ASCO’s Government Relations Committee and the board of the Association of Community Cancer Centers.

In describing the scope of the ACA, Dr. Penley said it is easier to follow the themes of the legislation than the specifics, many of which are likely to be modified, even if the specific regulations survive expected challenges.

The ACA was signed into law in March 2010 and has survived many threats, including a key challenge to the law’s constitutionality rebuffed by the U.S. Supreme Court in 2012. Due at least in part to its enormity and complexity, the provisions are being rolled out incrementally, with the last piece not planned for launch until January 2020. The ACA’s most well-known provisions—mandatory health insurance coverage, the creation of health insurance “exchanges” to buy individual policies, the abolition of penalties for pre-existing conditions—are set to begin at the end of this year, yet the far more comprehensive and detailed plans to control costs and improve quality—that is, the regulations that will most affect physicians—will be rolled out primarily in 2015.

“Language regarding quality runs all through the legislation along with a great deal of emphasis on establishing value in the context of cost efficiency,” Dr. Penley said.

Despite the length of the legislation, the ACA is more like a “framework,” said Steven Stranne, MD, JD, a lawyer with the firm Polsinelli, PC, based in Washington, D.C. Dr. Stranne, whose firm represents professional medical organizations, noted that Congress passed the ACA with the expectation that the federal agencies responsible for implementing the law will work to resolve any gaps, conflicts and ambiguities within the law along the way.

As a result, the effort to tease out and concentrate on specific issues within the ACA was likened by Dr. Stranne to “trying to take a drink from a fire hose.” In some cases, multiple interrelated issues are tackled simultaneously, with one solution likely affecting the others. Dr. Stranne acknowledged that it is challenging for individuals to determine “what is worth keeping track of.”

The Patient-Centered Outcomes Research Institute serves as one example. The institute was established when the bill was signed with the mandate to evaluate “relative health outcomes, clinical effectiveness and appropriateness” of treatment options. Although it has been compared to the United Kingdom’s National Institute for Health and Clinical Excellence (NICE), it does not have the power to regulate coverage. As a result, its influence at this point is difficult to gauge.

Although only bits and pieces of the ACA appear to be directly relevant to the practice of oncology, some changes can be identified, according to Dr. Penley. One example is that cancer survivors cannot be denied coverage based on their pre-existing cancer diagnosis. Another example, which will become law with provisions scheduled for enactment in January 2014, is that patients who participate in a clinical trial cannot be dropped by their insurer.

Of course, efforts to expand access to care have implications for oncology, just as they do for other areas of specialized care. Several studies have suggested that individuals without health insurance who develop cancer have poor outcomes at least in part because of diagnosis at a late stage. Although it is reasonable to expect a cancer diagnosis to be made earlier among those with access to health care, the Medicaid data is mixed, according to several experts, including Dr. Stranne. Several studies show that rates of late cancer diagnosis remain high among patients enrolled in Medicaid, and outcomes are only marginally superior to those without any health care coverage. This is not necessarily an indictment of the quality of care under Medicaid; rather, multiple factors may be contributing to delayed diagnoses, inadequate adherence to treatment, and poor outcomes in patients with low incomes.

The ACA does include several provisions to control costs, but Dr. Stranne reported that there has been a significant effort to avoid the word “rationing.” The fear of rationing has been a potent weapon for those who have fought the ACA, including the claim that the ACA would include “death panels” designed to refuse costly care to ill patients. The idea of health care rationing appears to be deeply unpopular even though it remains unclear whether universal access to treatment is affordable. Many provisions in the ACA are designed to “bend the cost curve,” but the effectiveness of some of these measures is difficult to predict.

ASCO does not currently have a task force specifically designed to monitor the ACA, according to Dr. Penley, but other task forces that follow legislation relevant to oncology practice are monitoring its developments.

For the community oncologist, there are many implications but few certainties. Only a modest change in the political balance is needed to threaten the very survival of the ACA. In a Kaiser Poll of public opinion reported earlier this year, about 40% of respondents favored the ACA, 40% opposed it, and 20% were unsure or had no opinion. If the ACA survives continued repeal attempts in Congress, modifications are expected. Even if there is no effort to change the intent of the law, some technical corrections appear necessary on the basis of the feasibility of key ACA provisions.

“Some politicians are reluctant to consider fixes because they just want the whole thing to be killed,” Dr. Stranne said.