As we write this piece, the future of healthcare reform in the United States remains uncertain. Keeping pace with the various healthcare proposals to replace the Patient Protection and Affordable Care Act (ACA) and the serious implications for patients with cancer and their access to high-quality, effective, and efficient cancer care is often challenging. Proposals that waive the requirement to cover essential health benefits would result in insurance plans without the necessary guardrails to ensure affordability and quality of coverage, especially for those with preexisting conditions such as cancer.1 Moreover, proposed reductions in Medicaid funding could leave the most vulnerable patient populations without affordable and timely access to optimal cancer diagnoses and evidence-based cancer treatment.2 Lost in the noise and rhetoric are the ways diverse stakeholders are stepping in to ensure that access to high-quality cancer care is not compromised. These stakeholders include policymakers, insurance companies, professional societies, patient advocacy organizations, and community organizations.
In the face of escalating partisan dynamics within the “repeal and replace” debate, some policymakers are working across the aisle to ensure that access to healthcare is not threatened by the absence of an agreeable, long-term healthcare policy. In an effort to stabilize the individual marketplace, the Senate Committee on Health, Education, Labor, and Pensions (HELP) Chairman Lamar Alexander (R-TN) and Ranking Member Patty Murray (D-WA), with 12 Democratic and 12 Republican cosponsors, introduced the Bipartisan Health Care Stabilization Act of 2017, which proposes to reinstate cost-sharing reduction (CSR) payments and stabilize the ACA's individual marketplaces. Moreover, this bipartisan agreement restores outreach and enrollment resources for 2018 and 2019 ACA health exchange open enrollment. According to the nonpartisan Congressional Budget Office (CBO), the bill would lower the federal deficit by nearly $3.8 billion during the next decade and would not reduce the number of people with health insurance.3 No prior Republican-backed proposal achieved deficit reduction while also preserving the number of covered lives. It remains unclear whether the Bipartisan Health Care Stabilization Act of 2017 will garner enough support to go to the Senate and then the House for a vote.
Earlier this year, Republican and Democratic governors came together to advocate for the continuation of Medicaid funding within their respective states, citing documented gains in coverage and access to care under the expansion. As of August 2017, Medicaid expansion states with Republican governors outnumbered expansion states with Democratic governors.4 Most notably, Republican governors Charlie Baker of Massachusetts, Rick Snyder of Michigan, John Kasich of Ohio, Asa Hutchinson of Arkansas, and Brian Sandoval of Nevada all voiced concerns regarding the elimination of Medicaid expansion under the various GOP replacement proposals, often going against the policy platform of their own political party. Recently, a group of 10 bipartisan governors wrote a letter in opposition to the Graham-Cassidy-Heller-Johnson legislation, urging the Senate to consider the bipartisan efforts of Chairman Lamar Alexander and Ranking Member Patty Murray to bring stability and affordability to the marketplace.5
In 2017, healthcare marketplaces established under the ACA experienced high-profile insurer exits, greater political uncertainty around long-term market sustainability, and ambiguity around the future of CSR payments. Even in the context of higher risks, several insurance companies decided to cover “bare counties”—areas with no insurer selling individual market coverage. According to the Kaiser Family Foundation, 82 counties comprising 92,000 consumers faced the prospect of having no exchange insurer in 2018.6 Centene Corporation, the nation's largest Medicaid managed care contractor, successfully provides insurance for low-income populations, a model that they use on the individual market. Shortly after appointing former CEO of Healthcare.gov Kevin Counihan to a leadership position, Centene stepped up to fill the void of “bare counties” in 3 new states (Kansas, Missouri, and Nevada). As a result of insurers like Centene stepping in, every county will have at least one insurer in the 2018 individual marketplace. Although coverage alone does not provide affordable and comprehensive insurance for everyone, it is a first step in ensuring that patients with cancer have timely access to high-quality care.
Throughout the debate on various GOP bills to “repeal and replace” the ACA, many professional societies remain constant in their response to the proposed bills: all Americans need access to affordable coverage and high-quality care through a stable healthcare insurance market. Professional societies and patient advocacy organizations express sustained, strong concerns over loss of coverage and, in turn, loss of access to healthcare. Ensuring access to evidence-based standards of care should be the cornerstone of coverage. Notably, we are seeing organizations that sometimes disagree on important issues in healthcare unite in their advocacy efforts. One example is the joint statement from the American Medical Association, American Academy of Family Physicians, American Hospital Association, Federation of American Hospitals, America's Health Insurance Plans, and the BlueCross BlueShield Association in response to the Graham-Cassidy-Heller-Johnson legislation.7 NCCN joined ASCO, Cancer Support Community, and the Leukemia & Lymphoma Society, among others, in response to this legislation, as well.
Significant funding cuts, a shorter enrollment period than in previous years, and consumer confusion over whether the ACA marketplace continues to exist have created substantial barriers to robust consumer participation in the 2018 Health Insurance Marketplace open enrollment period. In response, other stakeholders have strengthened their outreach efforts, including state governments, community navigator groups, and insurers. Although funding for outreach and advertisement was cut as by much as 90% by the Centers for Medicare & Medicaid Services (CMS) under the current administration, some states and navigator organizations have found ways to focus more funding on education through online tools, mobile applications, and targeted messages for younger consumers.8,9 Moreover, organizations are joining together to focus on enrollment efforts within their own communities. For example, the Cover NJ Coalition is a diverse group of association health plans and community social-service groups working together to encourage enrollment for New Jersey residents.10
The stakeholders identified previously should be recognized for their unifying work in an otherwise divisive political environment. Stakeholders are rising to the challenge of articulating how certain tradeoffs within the healthcare reform debate will significantly affect all patients, including those facing life-changing treatment choices for conditions such as cancer. It is our hope that stakeholders will continue to work together to advocate for healthcare reform that provides adequate coverage, access, and affordability throughout the cancer care continuum for all patients.
Patients Would Pay More for Less Coverage Under Senate Health Bill. American Cancer Society Cancer Action Network Web site. Available at: https://www.acscan.org/releases/patients-would-pay-more-less-coverage-under-senate-health-bill. Accessed November 6 2017.
NCCN Oncology Policy Program. NCCN Letter Regarding the American Health Care Act (AHCA). Available at: https://www.nccn.org/professionals/meetings/oncology_policy_program/pdf/2017_NCCN_AHCA_Letter_Walden_03-22-2017.pdf. Accessed November 6 2017.
Congressional Budget Office Cost Estimate. Bipartisan Health Care Stabilization Act of 2017. Available at: https://www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/bipartisanhealthcarestabilizationactof2017_0.pdf. Accessed November 5 2017.
Expansion States With Republican Governors Outnumber Expansion States With Democratic Governors August 2017. Kaiser Family Foundation Web site. Available at: https://www.kff.org/medicaid/slide/expansion-states-by-governor-party-affiliation/. Accessed November 5 2017.
HickenlooperJKasichJWalkerB. Bipartisan Governors Letter Re Graham Cassidy 9 19 17. Available at: https://www.colorado.gov/governor/sites/default/files/bipartisan_governors_letter_re_graham-cassidy_9-19-17.pdf. Accessed November 16 2017.
CareSource Steps in to Cover Last U.S. County Without Any ACA Exchange Coverage Option in 2018. FierceHealthcare Web site. Available at: http://www.fiercehealthcare.com/aca/caresource-steps-to-cover-last-bare-county-aca-exchanges. Accessed November 5 2017.
American Medical AssociationAmerican Academy of Family PhysiciansAmerican Hospital Association. Statement Regarding the Graham-Cassidy-Heller-Johnson Legislation. Available at: https://www.ahip.org/wp-content/uploads/2017/09/Joint-statement-AMA-AAFP-AHA-FAH-AHIP-BCBSA-9.23.17.pdf. Accessed October 1 2017.
LopezADemboskyA. NPR Web site. With Federal Funds Cut Others Must Lead Health Insurance Sign-Up Efforts. Available at: http://www.npr.org/sections/health-shots/2017/10/28/560225509/with-federal-funds-cut-others-must-lead-health-insurance-sign-up-efforts. Accessed November 5 2017.
LuhbyT. These States Are Doing Obamacare Open Enrollment Their Own Way. CNN Money Web site. Available at: http://money.cnn.com/2017/11/07/news/economy/obamacare-open-enrollment-state-exchanges/index.html. Accessed November 9 2017.
SmithE. After Funding Cuts Groups Step Up to Help With Obamacare Open Enrollment. Associations Now Web site. Available at: https://associationsnow.com/2017/10/funding-cuts-groups-step-help-obamacare-open-enrollment/. Accessed November 9 2017.