ACA: Effect on Patients With Chronic Conditions

Joseph Alvarnas, MD: For this last segment, we’d like to welcome back Elizabeth to help us try to better understand the future of the ACA. The newest administration has pulled back its plans for ACA replacement, at least as of this hour. Let’s discuss the impact of the ACA on cancer care since its implementation in March of 2010. Elizabeth, how has the ACA affected patients with chronic conditions like cancer?

Elizabeth Carpenter: That’s a great question. I think that it’s fair to say that tracking ACA repeal-and-replace efforts are by the minute at this point, so who knows what has happened while we’ve been in here chatting. But certainly, the Affordable Care Act had a number of provisions that were very beneficial to the patient community. The ACA increased access to care through the Medicaid expansion, increased subsidies to make insurance premiums more affordable, and also made some really fundamental changes to the insurance market: the idea that insurance companies have to sell to anyone regardless of preexisting conditions and that there are limits on how much premiums can vary. Those were all really beneficial to the patient community. Even as we’ve seen more people become insured, access challenges remain, and there are patients who still struggle to afford medications despite all the progress associated with the ACA.

Joseph Alvarnas, MD: How do you think—the 2 of you from the physician perspective—the ACA changed this for cancer or for chronic conditions like cancer? Given all that we’ve just heard, many of those things are things that we’ve looked for for years. The preexisting condition issue kept us from treating patients. I’ve had patients who couldn’t get care for that reason. Now that that’s gone, how has that evolved access?

John Fox, MD: I think we’re really faced with the fundamental question of whether or not access to healthcare is a right or a privilege. And I think that’s the debate that’s going on today. Practically speaking, though, the passage of the ACA provided access to healthcare to a host of patients who didn’t previously have a secure source of paying for their healthcare services. And they would not seek healthcare services until later in the course of their disease. So, I think everybody has recognized that the ACA has increased access, and I don’t know if we have good data that suggest we’re making earlier diagnoses, but we’re diagnosing patients who might not have otherwise sought care.

Joseph Alvarnas, MD: One of the elements you raised was that of Medicaid expansion, and I live in a state that doubled down on the Affordable Care Act. California went whole hog with this idea that they’re going to expand their state Medicaid program, which is called Medi-Cal. It now covers more than one-third of everyone living in California. There are about 40 million people living in California, so the scale of this is huge. The exchange was—and is still—quite robust, with about 11 plans. And then we have states like Texas who’ve not gone down that road. Looking at this on a case-by-case basis, do you think this has improved access in those states that have doubled down or who have implemented exchanges? And have health plans been on board with these changes—how have they partnered or not partnered in that process?

Elizabeth Carpenter: I could start that the biggest gains, in terms of reducing the uninsured that we’ve seen as a result of the Affordable Care Act, are certainly in those states that have expanded Medicaid. So, states like California have really seen the largest reduction in the number of uninsured patients in their state, not surprisingly, because of the Medicaid expansion. At the same time, you’ve still seen increased rates of Medicaid coverage in states that didn’t expand Medicaid—what we call the woodwork effect. People who were eligible for Medicaid prior to the Affordable Care Act, the outreach and enrollment associated with the law really had them come out of the woodwork, and now they’re insured.

You mentioned the exchange market. I think that is a piece of the Affordable Care Act that has fallen short of expectations. Enrollment is about half of what folks had predicted when the law was passed. That is the market that gets a lot of the attention in these repeal-and-replace debates, and I think we’ve seen, this week, a number of carriers announce that they are leaving that market. So, while the state of California is likely to have some pretty robust competition going forward, in other states, patients and insurance commissioners—and, frankly, federal and state lawmakers—will be faced with this decision about what to do if there’s no option on the exchange market for those individuals who qualify for extra assistance under the ACA.