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US cancer organisations weigh-in on health-care reform law
News
US cancer organisations weigh-in on health-care reform law Whatever might happen, key provisions in the health-care law might be difficult to repeal given their popularity among American citizens. A Kaiser Health Tracking Poll, taken days after the mid-term elections, showed that only 24% of the people polled want the entire law repealed and only 25% were in favour of repealing parts of the law. Overall, the report found that most people who support repeal of the law are in favour of keeping key provisions such as tax credits for small businesses offering insurance coverage, banning insurance companies from denying coverage on the basis of medical history or health conditions, gradual closing of the Medicare prescription drug doughnut hole, and financial subsidies to help low-income and moderate-income Americans purchase insurance. Overlying all of these possibilities is the simple fact that nobody really knows what will happen. What this means for oncologists and the delivery of cancer care in the USA is not exempt from this uncertainty—nobody knows, but there is speculation. Matthew Farber (Provider Economics & Public Policy at the Association of Community Cancer Centers, Rockville, MD) seems fairly certain that specific programmes in the health-care reform that would have affected cancer care are probably on the chopping block. Of these are programmes within the Office of Women’s Health in the HHS to subsidise early education for women at high risk of breast cancer, money for workforce issues that would have helped address such things as projected oncology staff shortages, and money to help hospitals implement patient navigation programmes. Safe, Farber thinks, are some of the more popular provisions such as the prohibition against insurers dropping coverage for pre-existing disorders, eliminating lifetime caps on insurance, coverage for children with
www.thelancet.com/oncology Vol 11 December 2010
pre-existing disorders, and coverage of dependents up to age 26 years. “It would be difficult for the Republicans to roll these back, not only because they are popular, but also because they are a major part of the entire health-care plan”, he said, adding that he and his colleagues are happy that these provisions will probably not be rolled back. If these programmes remain safe that would also please Okon, who emphasised the importance of these key provisions for cancer patients. “Annual and lifetime caps on insurance are especially important given the growing cost of cancer therapy”, he said. “Additionally, mandating that cancer patients covered by private insurance not be denied access to clinical trials and that all routine medical costs be covered are important provisions in the law.” Another important provision under the law is the creation of the Center for Medicare and Medicaid Innovation, he emphasised, adding that one of the listed projects within the new Center deals with cancer treatment planning and ongoing survivor-care planning. Expected to be in place by January, 2011, the new Center for Medicare and Medicaid Innovation will fund demonstration projects and pilot programmes aimed at reducing health-care costs while increasing quality.
For more on the Kaiser poll see http://www.kff.org/ kaiserpolls/8120.cfm/
Greg E Mathieson Sr/Landov/Press Association Images
As the campaign dust settles after a hard fought round of US mid-term elections that have emboldened the Republican party by handing them big wins at both the federal and state levels, what remains far from settled is what will become of the recently passed health-care reform law. Although repealing the health-care law was a main campaign pledge made by most of the Republican winners, the likelihood of accomplishing this is thought, given the Democratcontrolled Senate and Obama White House, to be slim to none in the next 2 years. “The promise to repeal and replace may be a good sound bite but is legislatively next to impossible because the Democrats still control the Senate and the White House”, said Ted Okon (Community Oncology Alliance, Washington, DC). “More likely, Republicans will try to strangle health-care reform by attacking the appropriations process.” Starving provisions of the law through the appropriations process by withholding funding of discretionary programmes or withholding funding from key departments, which need to expand staffing for the roll out of provisions in the bill—such as the Department of Health and Human Services (HHS) or Internal Revenue Service—is deemed the more plausible and likely outcome of the new balance of power in Washington in the near term. Another possible way of slowing down or disrupting implementation of various provisions of the law might come at the state level through Republican-controlled state legislatures and governorships who will be responsible for administering key provisions in the law, such as insurance exchanges and overseeing federally funded expansion of Medicaid. States might also challenge the law or specific provisions within it through the courts—several already have.
Results of the mid-term elections threaten health-care reforms
1121
Carolyn Kaster/AP/Press Association Images
News
Republican leaders could find their proposed cutbacks difficult to implement For ASCO’s statement see http://www.asco.org/ASCOv2/ Press+Center/Latest+News +Releases/ASCO+News/ASCO+ Statement+on+the+Passage+of +the+Patient+Protection+and+ Affordable+Health+Care+Act/
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Although the money to fund this new Center is subject to the appropriations process, Susan Dentzer (Health Affairs, Bethesda, MD, a health policy journal published by Project Hope), is highly sceptical that money will be withheld in the end. “It is hard to see how they will go after the $10 billion for the Center for Medicare and Medicaid Innovation when that is supposed to be a facilitator of payment and delivery system changes aimed at slowing the growth of health-care spending”, she said, adding that a number of Republicans in the Senate would block this because they think that the Center is a good investment. One key provision of the healthcare law that is generating substantial controversy is the individual mandate for all people to obtain insurance or be financially penalised. In the Kaiser Health Tracking Poll, this individual mandate was the only key provision that most Americans do not support. The mandate for the establishment of insurance exchanges and expansion of Medicaid enrolment to help fulfil this provision is creating a stir among states as they look to rampup enrolment of the nearly 50 million people nationwide uninsured so far. Although most states are taking steps to meet the 2014 deadline for implementation of the exchanges and Medicaid expansion, several states are showing signs of delaying
implementation preparation by, for example, not requesting available federal funds to help develop these exchanges. Dentzer does not see this as a real threat. “We are talking about creating vibrant new competitive markets for health insurance that will give many consumers more and better choices for health insurance than ever before with more transparency of health plans than ever before”, she said, adding that since these exchanges will also be the portal for people covered by Medicaid as well as private insurance, governors will not want the federal government to come in to set up the exchanges in their states and will prefer to have their own state do it. Even with the push in the current law to provide coverage of uninsured people, oncology groups in the USA are still concerned that many people will not have access to the cancer care they need. An official statement by the American Society of Clinical Oncology (ASCO) states although “ASCO supports improved access to health care for millions of Americans, uninsured cancer patients still won’t have sufficient coverage”. Speaking on behalf of the American Association of Cancer Research, Jon Retzlaff (Philadelphia, PA), also expressed concern over the continual problem with the provision of access to cancer care for all, including people such as the homeless who are often not even in the discussion. “The success that has come from cancer research is phenomenal in many areas”, he said, “but its application to cancer patients across the country is uneven to say the least because many people do not have access to care, are not seen early enough by an oncologist, and are not getting screened”. One provision in the current healthcare bill that he thinks crucial for underserved people is the $11 billion provision to subsidise community health centres to serve an additional
20 million people, since these are the centres that provide needed services for low-income and underserved people. Retzlaff worries that this money might be provided through the types of discretionary funds that can be withheld through the appropriations process. Even if patients have access to care, said Okon, a major problem that remains unaddressed by the current health-care reform law, and could become worse if it remains unchanged, is the growing problem of Medicare cancer patients who have no or insufficient secondary insurance to cover the 20% co-payment obligation. “In cancer care, having insurance coverage does not guarantee that patients will have access to care”, he said. “Subsidising community healthcare centres and creating insurance exchanges will not solve the cancer care crisis.” He also expressed concern that the newly created Independent Medicare Advisory Board (IPAB), which can cut Medicare spending when targets are exceeded, will further reduce reimbursement to oncologists who treat Medicare cancer patients. “None of this is good for cancer care”, he said. Of course oncologists remain concerned that a provision to permanently fix the Sustainable Growth Rate formula used to calculate physician pay rates for Medicare patients was taken out of the bill. “This is hard for our membership because although Congress stops these cuts regularly, there remains a lot of uncertainty about what the formula will be replaced with”, said Farber. Whether or how these ongoing problems with Medicare and Medicaid, similar to all the challenges posed by the new health-care reform law, will be addressed by the new power balance in Washington is yet to be seen.
Mary Beth Nierengarten
www.thelancet.com/oncology Vol 11 December 2010
US cancer organisations weigh-in on health-care reform law Whatever might happen, key provisions in the health-care law might be difficult to repeal given their popularity among American citizens. A Kaiser Health Tracking Poll, taken days after the mid-term elections, showed that only 24% of the people polled want the entire law repealed and only 25% were in favour of repealing parts of the law. Overall, the report found that most people who support repeal of the law are in favour of keeping key provisions such as tax credits for small businesses offering insurance coverage, banning insurance companies from denying coverage on the basis of medical history or health conditions, gradual closing of the Medicare prescription drug doughnut hole, and financial subsidies to help low-income and moderate-income Americans purchase insurance. Overlying all of these possibilities is the simple fact that nobody really knows what will happen. What this means for oncologists and the delivery of cancer care in the USA is not exempt from this uncertainty—nobody knows, but there is speculation. Matthew Farber (Provider Economics & Public Policy at the Association of Community Cancer Centers, Rockville, MD) seems fairly certain that specific programmes in the health-care reform that would have affected cancer care are probably on the chopping block. Of these are programmes within the Office of Women’s Health in the HHS to subsidise early education for women at high risk of breast cancer, money for workforce issues that would have helped address such things as projected oncology staff shortages, and money to help hospitals implement patient navigation programmes. Safe, Farber thinks, are some of the more popular provisions such as the prohibition against insurers dropping coverage for pre-existing disorders, eliminating lifetime caps on insurance, coverage for children with
www.thelancet.com/oncology Vol 11 December 2010
pre-existing disorders, and coverage of dependents up to age 26 years. “It would be difficult for the Republicans to roll these back, not only because they are popular, but also because they are a major part of the entire health-care plan”, he said, adding that he and his colleagues are happy that these provisions will probably not be rolled back. If these programmes remain safe that would also please Okon, who emphasised the importance of these key provisions for cancer patients. “Annual and lifetime caps on insurance are especially important given the growing cost of cancer therapy”, he said. “Additionally, mandating that cancer patients covered by private insurance not be denied access to clinical trials and that all routine medical costs be covered are important provisions in the law.” Another important provision under the law is the creation of the Center for Medicare and Medicaid Innovation, he emphasised, adding that one of the listed projects within the new Center deals with cancer treatment planning and ongoing survivor-care planning. Expected to be in place by January, 2011, the new Center for Medicare and Medicaid Innovation will fund demonstration projects and pilot programmes aimed at reducing health-care costs while increasing quality.
For more on the Kaiser poll see http://www.kff.org/ kaiserpolls/8120.cfm/
Greg E Mathieson Sr/Landov/Press Association Images
As the campaign dust settles after a hard fought round of US mid-term elections that have emboldened the Republican party by handing them big wins at both the federal and state levels, what remains far from settled is what will become of the recently passed health-care reform law. Although repealing the health-care law was a main campaign pledge made by most of the Republican winners, the likelihood of accomplishing this is thought, given the Democratcontrolled Senate and Obama White House, to be slim to none in the next 2 years. “The promise to repeal and replace may be a good sound bite but is legislatively next to impossible because the Democrats still control the Senate and the White House”, said Ted Okon (Community Oncology Alliance, Washington, DC). “More likely, Republicans will try to strangle health-care reform by attacking the appropriations process.” Starving provisions of the law through the appropriations process by withholding funding of discretionary programmes or withholding funding from key departments, which need to expand staffing for the roll out of provisions in the bill—such as the Department of Health and Human Services (HHS) or Internal Revenue Service—is deemed the more plausible and likely outcome of the new balance of power in Washington in the near term. Another possible way of slowing down or disrupting implementation of various provisions of the law might come at the state level through Republican-controlled state legislatures and governorships who will be responsible for administering key provisions in the law, such as insurance exchanges and overseeing federally funded expansion of Medicaid. States might also challenge the law or specific provisions within it through the courts—several already have.
Results of the mid-term elections threaten health-care reforms
1121
Carolyn Kaster/AP/Press Association Images
News
Republican leaders could find their proposed cutbacks difficult to implement For ASCO’s statement see http://www.asco.org/ASCOv2/ Press+Center/Latest+News +Releases/ASCO+News/ASCO+ Statement+on+the+Passage+of +the+Patient+Protection+and+ Affordable+Health+Care+Act/
1122
Although the money to fund this new Center is subject to the appropriations process, Susan Dentzer (Health Affairs, Bethesda, MD, a health policy journal published by Project Hope), is highly sceptical that money will be withheld in the end. “It is hard to see how they will go after the $10 billion for the Center for Medicare and Medicaid Innovation when that is supposed to be a facilitator of payment and delivery system changes aimed at slowing the growth of health-care spending”, she said, adding that a number of Republicans in the Senate would block this because they think that the Center is a good investment. One key provision of the healthcare law that is generating substantial controversy is the individual mandate for all people to obtain insurance or be financially penalised. In the Kaiser Health Tracking Poll, this individual mandate was the only key provision that most Americans do not support. The mandate for the establishment of insurance exchanges and expansion of Medicaid enrolment to help fulfil this provision is creating a stir among states as they look to rampup enrolment of the nearly 50 million people nationwide uninsured so far. Although most states are taking steps to meet the 2014 deadline for implementation of the exchanges and Medicaid expansion, several states are showing signs of delaying
implementation preparation by, for example, not requesting available federal funds to help develop these exchanges. Dentzer does not see this as a real threat. “We are talking about creating vibrant new competitive markets for health insurance that will give many consumers more and better choices for health insurance than ever before with more transparency of health plans than ever before”, she said, adding that since these exchanges will also be the portal for people covered by Medicaid as well as private insurance, governors will not want the federal government to come in to set up the exchanges in their states and will prefer to have their own state do it. Even with the push in the current law to provide coverage of uninsured people, oncology groups in the USA are still concerned that many people will not have access to the cancer care they need. An official statement by the American Society of Clinical Oncology (ASCO) states although “ASCO supports improved access to health care for millions of Americans, uninsured cancer patients still won’t have sufficient coverage”. Speaking on behalf of the American Association of Cancer Research, Jon Retzlaff (Philadelphia, PA), also expressed concern over the continual problem with the provision of access to cancer care for all, including people such as the homeless who are often not even in the discussion. “The success that has come from cancer research is phenomenal in many areas”, he said, “but its application to cancer patients across the country is uneven to say the least because many people do not have access to care, are not seen early enough by an oncologist, and are not getting screened”. One provision in the current healthcare bill that he thinks crucial for underserved people is the $11 billion provision to subsidise community health centres to serve an additional
20 million people, since these are the centres that provide needed services for low-income and underserved people. Retzlaff worries that this money might be provided through the types of discretionary funds that can be withheld through the appropriations process. Even if patients have access to care, said Okon, a major problem that remains unaddressed by the current health-care reform law, and could become worse if it remains unchanged, is the growing problem of Medicare cancer patients who have no or insufficient secondary insurance to cover the 20% co-payment obligation. “In cancer care, having insurance coverage does not guarantee that patients will have access to care”, he said. “Subsidising community healthcare centres and creating insurance exchanges will not solve the cancer care crisis.” He also expressed concern that the newly created Independent Medicare Advisory Board (IPAB), which can cut Medicare spending when targets are exceeded, will further reduce reimbursement to oncologists who treat Medicare cancer patients. “None of this is good for cancer care”, he said. Of course oncologists remain concerned that a provision to permanently fix the Sustainable Growth Rate formula used to calculate physician pay rates for Medicare patients was taken out of the bill. “This is hard for our membership because although Congress stops these cuts regularly, there remains a lot of uncertainty about what the formula will be replaced with”, said Farber. Whether or how these ongoing problems with Medicare and Medicaid, similar to all the challenges posed by the new health-care reform law, will be addressed by the new power balance in Washington is yet to be seen.
Mary Beth Nierengarten
www.thelancet.com/oncology Vol 11 December 2010