In this interview we discuss how the ACA, which was passed in 2010, changed the way oncologists treat their patients, and how a repeal of the law would affect patients’ access to care.
1.As we begin 2017, members of Congress are taking steps that could lead to the repeal of the Patient Protection and Affordable Care Act (ACA). The ACA, which was passed in 2010, made sweeping changes to healthcare law and patients’ access to care. How has the ACA changed the way oncologists treat their patients?
Dr. McAneny: To answer that question I would like to explain a little bit about my practice here in New Mexico. New Mexico has a Republican governor, and we did expand Medicaid to people who were between 100% and 137% of the Federal Poverty Level. We created a not-for-profit insurance company to be able to provide individually owned insurance for patients. In New Mexico, we have long had a high-risk pool, but it is unaffordable for many patients and does not have the ability to get patients what they need in a timely manner. In fact, we have a several-year waiting list for people to get into the high-risk pool. Obviously, for cancer patients, you can’t wait a couple of years to treat your cancer. The high-risk pool wasn’t helping.
When the ACA was enacted, our Republican governor expanded Medicaid and we started the community-oriented and -operated plan that we call New Mexico Health Connections. We were able to drop our uninsured rate from 24% to about 16%. Sixteen percent is still too high, but what this meant for me as an oncologist taking care of patients is that I would be able to bring patients into the practice and be able to purchase the drugs that they need. I can see a patient in an exam room, and I could potentially even do that for free, but nobody other than the insurance companies can afford to purchase expensive chemotherapy for patients. The ACA allowed us to get these patients on treatment. To me, that was a very important event. It is heartbreaking to have a patient whom you know you could treat, but economic barriers prevent you from doing so. The ACA took away at least some of those.
2.There seems to be a divide in the medical community about whether the ACA is really an effective program, or if it just puts more burden on the treating physician. What do you think is the reason for this difference of opinion?
Dr. McAneny: I do think that it was overpromised and underfunded to a great extent. When you have individuals who have never had insurance before and they sign up for the cheapest possible plan-a Bronze plan-they would find that their deductible could be as high as $6,400 when they tried to use the insurance for care. Patients with cancer would come into my practice, needing treatment, and I would have to explain that the first $6,400 comes out of their pocket. These are people living at 150% of the Federal Poverty Level. They have-and the average American has-on hand about $500 to use for an emergency. They don’t have $6,400.
The patients then become angry with the practice because we must explain to them that their plan requires that they pay this money upfront before the real insurance part of it kicks in. That puts a huge burden on the physician, and it means that we are at risk of providing the first $6,400 worth of services for which we will never be able to collect payment. These people simply do not have the money. Also, if they stop paying their premiums, they have a 3-month grace period in which they are still covered, but the insurance companies have the ability to stop paying us even though they are telling us the patient is covered. We don’t have a good mechanism to know that this patient is really on the plan or not on the plan. It puts us in the situation of being at risk for expensive therapies that we never get paid for, trying to police our patients to see if they are paying their premium bills, or ending up having to abandon patients midway through a cycle because now they are uninsured and we cannot as a practice afford to purchase the drugs or turn on the linear accelerator if we are not going to get paid for the cost of those services. That is a significant problem for us.
Some of the features of the ACA that worked well were preventing insurance companies from being able to reject patients for coverage because of preexisting conditions, and letting children be covered on their parents’ plans until age 26.
3. If Congress repeals the ACA, this may mean that preexisting conditions, including cancer, soon may not be covered by medical insurance. If this occurs, how will it impact oncology practice, specifically community oncology practices?
Dr. McAneny: If a patient receives a cancer diagnosis and his or her insurance gets canceled due to the repeal of the ACA, then we are in the same position as treating someone who is uninsured because the cancer is now a preexisting condition that disqualifies that person from obtaining insurance. In a process called rescission, patients with a new diagnosis of cancer would have to deal with the insurance companies going back through their previous applications and finding that they forgot to mention that they had seen a dermatologist for a squamous cell skin cancer that was frozen off in the office, and they would say, “Ah-ha! You had a preexisting condition and now you are not covered for your cancer today.”
We would end up spending a huge amount of time writing letters, trying to get patients reinstated so that we would be able to treat them. That would be painful. Painful for the patients, and painful for doctors who have to try to help patients file an appeal with insurance companies.
Another concern about one of the current suggestions for how the ACA might be replaced is that patients would be allowed to buy insurance across state lines. My problem with that is when we get a patient from out of state, insurers often don’t pay us for the care we give. I recently had a patient from out of state who needed a particular drug. We called the insurance company and they said that we did not need a prior authorization, so we gave the drug and then when the bill was sent, the patient’s insurance company said that the drug was supposed to go through a specialty pharmacy and wouldn’t pay for it. If we are practicing across state lines with patients who have insurance from another state and we are taking care of the only patient they have in our area, why on earth would they pay us? They can just find some reason to deny the claim, and no community oncologist can afford to fight every single denial from health plans all across the country. You can’t be in-network with all of these insurance companies. That policy would certainly affect oncology practices.
Unless the current requirement that preexisting conditions cannot be a reason to deny insurance is preserved under a replacement plan, it would mean that any patient we see, even if he or she had a thyroid cancer with a very high rate of being cured, would struggle to get insurance. I generally remind oncologists and the general public that 10% of cancers occur in people who have had a previous cancer. That means that all of those patients will be uninsured. We know from years of data that patients who are uninsured live sicker and die younger than patients who have insurance. It will very much affect oncology practices because it will limit the number of people that we are able to help.
4.The possible repeal of the ACA has many cancer patients worried that they will no longer be able to afford the treatments they need. What is your advice to those people, and what steps should they take to protect themselves?
Dr. McAneny: The first thing we are telling people to do right now in our state is to talk to the New Mexico Health Insurance Exchange and see if they can get on a plan. President Trump has stated that he does not intend to throw anybody who currently has insurance, off insurance.
We are encouraging people in the open enrollment period to get on insurance and make sure that they pay their premiums. One of the possible insurance remedies that is being considered as the “replace” part of “repeal and replace” is that if anybody misses a payment they are uninsured for a year. This would kill a cancer patient. I know how easy it is, from personal experience, to miss a bill and then pay it later when you find it-even if it is not your intent to ever do that. I worry about what that might do to our patients, and how community oncologists are going to manage this if we have patients halfway through a course of chemotherapy and then all of a sudden their insurance gets dropped because they were sick and missed the bill coming in the mail.
I tell patients to work with a caregiver to make sure that they are signed up for insurance, and to make sure they keep those premiums coming. Unfortunately, we are not allowed to help patients when they need help with their premiums. We can do that for insured patients who had employer-based coverage and have a COBRA payment. We can assist them with that, but we can’t, as a practice, assist them with premiums for the ACA policies.
Patients also need to get their preventive services taken care of as soon as possible. Get that colonoscopy done while it is free under the ACA. Make sure your mammograms are up to date. These things are important for people to do to protect themselves.
5.Many experts say that repealing the ACA without a sufficient replacement would be “catastrophic” to people’s health and to the health insurance market. Do you agree?
Dr. McAneny: The responsible thing for the new administration to do is to come up with a replacement plan so that we can reassure millions of Americans that they will not be without coverage, especially cancer patients who cannot wait for the wheels of bureaucracy to turn. I remember a patient I took care of who was a Marine and never thought he would need health insurance because he was so healthy, until he developed Hodgkin disease, which is curable-but with expensive medications. We were able to get him on an individual plan and he was able to get treated without having to go into bankruptcy.
I look at health insurance as an essential function. None of us, except for the 0.001%, can afford to pay for acute leukemia treatment out of our pockets. We need to have our risk pooled so that if you are the unlucky one who gets cancer, then you have insurance that will pay for treatment. That is the basic premise of insurance.
We absolutely have to have insurance markets that accurately address what the premiums should be, and that pay the claims in an expeditious way so that practices can stay in business. If we, for example, got rid of a preexisting condition requirement without requiring that everybody get insurance, we would end up with people getting insurance as soon as they get sick. A patient would go to the doctor, get a blood count, and if the doctor was worried about leukemia, the patient would run home and sign up for insurance. That doesn’t work for an insurance market. Insurance companies have to be able to predict their future expenses in order to price their policies in a way that allows them to stay in business.
The best thing, not only for the people who need insurance, but for the insurance market and for physicians and physician practices, is to have a replacement plan available before the ACA is repealed, so that practices, as small businesses, can figure out how to manage under the new system and survive, make payroll, keep the lights on, and keep delivering healthcare.