Impact of Insurance Subsidies on Cancer Care

Transcript

00:00 --> 00:06Announcer Funding for Yale Cancer answers is provided by Smilow Cancer Hospital.
00:06 --> 00:22Announcer Welcome to Yale Cancer answers with the director of the Yale Cancer Center, Doctor Eric Winer. Yale Cancer Answers features conversations with oncologists and specialists who are on the forefront of the battle to fight cancer. Here's Doctor Winer.
00:22 --> 00:53Dr. Winer Tonight we're talking about, a subject that touches the lives of many patients and their families, both here in Connecticut and across the country. And that is the impact of insurance subsidies on cancer care and disparities in cancer outcomes that may only worsen because of the, the limited, ability for patients to obtains subsidies at the present time.
00:54 --> 01:27Dr. Winer For many patients, insurance services subsidies have provided a critical lifeline to afford life saving care. But for others, gaps in coverage or access can leave them vulnerable to delayed diagnoses. An inability to, access treatment in some cases. And what we worry about most, of course, is ultimately poor outcomes from the standpoint of their cancer. Joining me, this evening is a leading voice on this issue.
01:27 --> 02:05Dr. Winer Doctor Tracy Battaglia, professor of medicine at Yale School of Medicine and associate director of Y, seeks community outreach and engagement program. Tracy spent much of her career at Boston Medical Center, just 100 plus miles north of here, where she also focused on health care equity and enjoying this. Now, just under two years ago, to tackle these issues, so without further ado, why don't we get going?
02:05 --> 02:08Dr. Winer Tracy, it's so nice to have you here tonight.
02:08 --> 02:12Dr. Battaglia Thank you, doctor Winer, it's my pleasure to join you.
02:12 --> 03:08Dr. Winer And, and feel free, of course, to call me Eric. Before we dive into the details, I want to frame this conversation for our listeners. Cancer care is, unfortunately, super expensive. The drugs themselves are at times, just over the top. Expensive. And then beyond drugs. There are scans and blood tests and all sorts of other very, very expensive components of the treatment, not to mention surgery, radiation, therapy, and visits with medical oncologists, insurance subsidies, can play a big role in, leveling the playing field.
03:08 --> 03:44Dr. Winer Although it by no means are these subsidies a cure all. And we still have real challenges in terms of having patients, deal with all of the financial issues, that surround cancer treatment and as we've talked about previously on this show, there are many patients who suffer what we think of as significant financial toxicity or, essentially, the high chance of going into debt as a result of their cancer treatment.
03:44 --> 03:57Dr. Winer With that background, Tracy, what are insurance subsidies? How have they worked in the US in recent years? And what's changed as of January 1st?
03:57 --> 04:10Dr. Battaglia Thank you for that framing, Eric. And, the invitation to call you Eric to take you up on, I want to provide some of my own framing before I answer that question if it's okay.
04:10 --> 04:11Dr. Winer Yeah, absolutely.
04:11 --> 04:25Dr. Battaglia And that is to sort of just acknowledge the conversation. We're having this evening around. Insurance is one very important component of ensuring equitable access to care, but it is only one of only one piece.
04:25 --> 04:26Dr. Winer Absolutely.
04:26 --> 04:50Dr. Battaglia And the reason that I think you asked me to join you in this conversation is that, you know, I'm passionate about ensuring equitable access to cancer care, and I don't want to mislead our audience members in thinking that insurance subsidies or any insurance coverage is the one and only answer. It is one of many levers we need to be pulling at the same time to ensure equal access.
04:50 --> 05:11Dr. Winer And I can I just jump in with one comment, which is all the money in the world. Yeah. And for that matter, entirely free care for everyone. Still wouldn't solve all the problems related to disparities in health care and specifically in cancer care.
05:11 --> 05:32Dr. Battaglia Right. And and I think that, you know, as I think about insurance subsidy is some they're more of a sort of treating a symptom of the larger problem than, you know, really getting at the root cause. And I know we're going to dig into that throughout our conversation. But let me let me go back to your question and see if I can frame it.
05:32 --> 06:00Dr. Battaglia And I'll break this down in a very sort of simple sort of response, because I am not a policy researcher by any stretch of the imagination, but, understand enough about the Affordable Care Act to sort of answer the question. So, as we all know, in 2014, the Affordable Care Act, went into effect and there were many components of the Affordable Care Act to achieve its ultimate goal, which is to make insurance affordable and ensure equal coverage for all.
06:00 --> 06:26Dr. Battaglia I mean, that was the essentially the intent of the Affordable Care Act. And one of the things the Affordable Care Act did was establish these exchanges where individuals without employer based insurance coverage could go to seek coverage in a way that was affordable to them, because it was subsidized by directly through the federal government, but differently from state to state.
06:26 --> 06:54Dr. Battaglia And so, in 2014, these exchanges went into place because our country is largely driven by employer based insurance. And this was an attempt to sort of fill that gap, the gap that exists between very poor people who are eligible for Medicaid, elderly people who are eligible for Medicare, and those who are employed or working for very small companies who don't offer sort of insurance coverage.
06:54 --> 07:30Dr. Battaglia So those, that went into effect in 2014 and between 2014 and 2020, these subsidies were paid basically on a sliding scale basis based on your income. And so you could go on to the exchange if you live in Connecticut. And, put in your information about your, income and you can get insurance, compare different insurance plans that you would be eligible for and that it would explain your, costs to you personally and the cost to, you know, the state coverage, much like our employers.
07:30 --> 08:07Dr. Battaglia Right? We share, the burden of, of, insurance, premiums with our, our employers and in these in this case with the ACA, it's shared by the federal government through our states. And so that significantly improved our ability to improve coverage. For those who didn't previously have insurance. And then Covid happened in 2020, and there was an additional, legislation that went into effect in 2021 through the American Rescue Plan Act that then allowed actually even more subsidy coverage.
08:07 --> 08:28Dr. Battaglia So, almost covering 100% of premiums for certain populations as of December 31st, 2025. Those subsidies and that legislation sort of expired. And to date, our federal government has not, come up with an alternative plan to cover that.
08:28 --> 09:03Dr. Winer And what this means, if I am correct, and please correct me if I'm that, is that people who were receiving these subsidies so that they could afford to purchase health insurance have found themselves in a position where they may be spending hundreds, if not thousands of dollars, monthly, certainly annually. To to purchase health coverage resulting for some people in an inability to purchase that coverage.
09:04 --> 09:04Dr. Winer Right.
09:04 --> 09:31Dr. Battaglia And so it can certainly so you know the the impact on an individual is going to depend on their own personal financial situation and the state they live in. And so we're very fortunate in the state of Connecticut, if you, like me, googled, our Connecticut, Access Health, website to see what would happen if I were on the exchange and wanted to know what I should be doing.
09:31 --> 09:58Dr. Battaglia If you go to the page, you'll see that the, our state has stepped up and is managing the loss of the federal ACA subsidies by using its own state funds. And so specifically, they have allocated $70 million from a reserve fund to keep the health insurance costs stable for many. And so many may not notice an immediate impact in the state of Connecticut.
09:58 --> 10:01Dr. Battaglia But this is not a long term solution.
10:01 --> 10:36Dr. Winer Yeah. And I think that what many of us are worried about is that there will be people and perhaps the state of Connecticut will avoid this problem to a greater extent than other states. But there will be many people who will say, I just can't afford health coverage. That doesn't, however, prevent them from getting sick. It doesn't prevent them from at times developing a cancer diagnosis and so when they develop cancer without health care coverage, there are really two choices.
10:36 --> 11:09Dr. Winer One, they can just not get care, or two, they can go to a facility and sadly rack up, a tremendous amount of debt. And of course, we'd prefer to see that than for people not to get care. But it it puts individuals in a very difficult, difficult situation for that matter. It also puts some hospitals in, in a very precarious situation because hospitals do ultimately have to provide care, particularly emergency care.
11:09 --> 11:24Dr. Winer And if, if that's not reimbursed in any way, hospitals and this is often very much true for smaller hospitals, could just suffer terrible financial consequences.
11:24 --> 11:33Dr. Battaglia Yeah. I think what you're getting at is that the cost that the lack of subsidies just shifts the cost burden.
11:33 --> 11:49Dr. Winer Totally. I mean, well, I, you know, so tragically, maybe it results in less health care being delivered because some people just decide not to get it, which is horrific. And then for others, it just shifts the burden, it increases costs.
11:49 --> 11:50Dr. Battaglia Because what.
11:50 --> 11:51Dr. Winer Is true here.
11:51 --> 12:24Dr. Battaglia Is that later stage disease costs a lot more. And so if and the data is pretty clear that with subsidies and with the ACA and increased coverage. Right. I think the statistics are, subsidies, under the ACA, reduced UN insurance rate among non elderly adults from 16% in 2010 to 8.6% in 2022. So essentially reduced in half the millions of Americans who are uninsured.
12:24 --> 12:41Dr. Battaglia And what we know about those who have insurance, they're more likely to engage in services like cancer screening, show up and get diagnosed at an earlier stage, and cost of treatment and outcomes improve when you have an earlier diagnosis.
12:41 --> 13:14Dr. Winer You know, and there's there has been evidence over the past, oh, five plus years that as a result of, as a, as, as a result of the ACA, that in fact, in states that embraced, the ability to, to take advantage of this, cancer care improved and outcomes improved. This has been seen in a variety of different diseases.
13:14 --> 13:42Dr. Winer So, you know, this is just so very important. We're going to have to take a, a brief break. We've only covered about two of the ten questions that I had for you, but, and I think the, the, our listeners can tell how how concerned both you and I are about this entire subject. But when we come back, we'll, we'll go a little further.
13:42 --> 13:53Dr. Winer What we'll talk about, the, the impact that this and other disparities have very specifically on patients and their family members.
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15:03 --> 15:37Dr. Winer Welcome back to our second half of Yale Cancer Answers. Tonight, I'm joined by our guest, Doctor Tracy Battaglia, professor of medicine at Yale School of Medicine and the associate director within our cancer center for Community Outreach and Engagement. We're talking about the, elimination of federal health insurance subsidies tonight, as of January 1st, and the potential impact that it has on patients.
15:37 --> 16:00Dr. Winer We we touched on the fact that Connecticut has taken steps to use state money to make up for what the federal government is no longer providing. Tracy, when Medicare expansion first, became available as a result of the ACA, where did Connecticut stand with that?
16:00 --> 16:02Dr. Battaglia So I think you mean Medicaid expansion.
16:02 --> 16:05Dr. Winer Oh, I'm sorry, did I say Medicare or. Excuse me?
16:05 --> 16:46Dr. Battaglia No, no, no. So, yes, Medicaid expansion, was actually, one of the other Affordable Care Act permissions. Right? So in addition to the, exchanges with the subsidies for those, who were eligible for and who were not eligible for Medicaid, there was also the opportunity to expand Medicaid eligibility criteria. So essentially allowing adults with incomes up to 138% of the poverty level, which is significantly higher than prior, after the Affordable Care Act.
16:46 --> 16:57Dr. Battaglia And Connecticut was the first state fun fact, in the country to adopt Medicaid expansion after the Affordable Care Act allowed it. So we were early adopters of Medicaid expansion.
16:57 --> 17:02Dr. Winer And do you know how many states chose not to adopt Medicaid expansion?
17:02 --> 17:08Dr. Battaglia I think to date, 40 states plus Washington, D.C., have adopted expansion.
17:08 --> 17:26Dr. Winer Yeah. And, and, you know, I referred earlier to the fact that there has been evidence that, that the ACA resulted in improved cancer outcomes. That was in states, that very specifically adopted Medicaid expansion.
17:26 --> 17:50Dr. Battaglia Absolutely. I mean, often Medicaid is a proxy for, income when we do sort of health services research and we see poorer outcomes when we compare Medicare, Medicaid patients to other patients, because as I said, it's a proxy for sort of income. But we also see uninsured patients do worse than those on Medicaid when they have access.
17:50 --> 18:15Dr. Battaglia And there's certainly evidence to Medicaid expansion literature demonstrating improved outcomes. Both in, in, in outcomes for patients but also net savings for actually a lot of states for things we were talking about earlier, which are that people, you know, show up at earlier stage and they don't cost the health systems as much, when they do, have coverage.
18:15 --> 18:46Dr. Winer So of course, the most extreme example of that is somebody not only being diagnosed at a more advanced stage, but someone waiting until they need truly urgent or emergent care and presenting to emergency rooms, which is in fact the most expensive care. And thankfully, our hospitals have to take care of people who are truly in need of emergency care.
18:46 --> 19:19Dr. Winer So it guarantees care, but it guarantees a very expensive type of care. You were talking, with me just briefly in the break about the fact that people who have benefited from these insurance subsidies tend to be people who are at the lower income levels. These also tend to be people who face other types of disparities. You want to just comment on that a little bit because it's it's as if we're we're taking the most vulnerable.
19:19 --> 19:21Dr. Winer And now making them even more vulnerable.
19:21 --> 20:15Dr. Battaglia Yeah. We started our conversation talking about how complex disparities or inequities in cancer care and cancer outcomes are, and the fact that insurance coverage is one of many levers we need to pull to sort of really get at the root cause of the problem. But what we do know about, those who are eligible for subsidies, right, which is sort of the Band-Aid that the ACA sort of put in place tend to be the low income individuals who tend to come from racial, ethnic minority, backgrounds and populations and, and by definition, already present with other barriers to care, including preexisting conditions.
20:16 --> 20:46Dr. Battaglia Lack of, you know, preventive care, other social sort of determinants of health that impede their ability to access care equally with counterparts who don't have those barriers. So the subsidies essentially try to level the playing field a little bit, but not 100%. And so the lack of these subsidies has the potential to sort of roll us back in history in terms of our ability to achieve equitable share.
20:46 --> 21:16Dr. Winer Yes. It's it is really so difficult. And it it never ceases to amaze me that, we are a country where we have some of the very best, if not the best medical care in the world. And yet that's not care that's available to everyone. And some people just don't have the kind of access for for a whole range of reasons that you were talking about.
21:17 --> 21:56Dr. Battaglia It is astounding. And and as you know, I've shared with you my own personal cancer history, you know, as a a white professional diagnosed with cancer, first at the age of 20 and then again at the age of 40, my experience at 20 and then again at 48 was starkly different from the experiences of many of my patients who come from different backgrounds and my outcomes, my outcome, which, you know, my outcomes, which were very favorable, were not the same as many of the outcomes that I've experienced with patients that I've cared for in similar situations.
21:56 --> 21:58Dr. Battaglia And it's just not acceptable.
21:58 --> 22:42Dr. Winer It, it isn't. So what can we as physicians and other health care providers do at this time? In terms of counseling patients about, the, the, the subsidies going away? It's, you know, in Connecticut, at least in the short term, we may have fewer problems. There are people who listen to this show beyond the Connecticut borders, I hope, and, for people who don't live in Connecticut and for that matter, who those who do and worry about what will happen long term, what should we be telling patients and how can we help them deal with this?
22:42 --> 23:18Dr. Battaglia I mean, I think that my message is that there should be concern about this. And it's going to affect all of us. We'll all be affected by, the lack of, support and resources for all to, to access, you know, quality, timely cancer care. I mean, for those of us in Connecticut, I think in the short term, the message is, you know, there is no, the fact that the sky is not falling bright, you shouldn't notice a major change in your coverage.
23:18 --> 23:50Dr. Battaglia But for anyone with a cancer diagnosis, we know that even with insurance, there's significant out-of-pocket expenses. And we referenced the term financial toxicity earlier. Cancer care is exceedingly expensive, and as treatments and, options expand for patients, so do the costs. And so even with insurance, there are significant out-of-pocket expenses that patients need to be prepared for and to understand.
23:50 --> 24:17Dr. Battaglia And so I think one of the most important things is for people to understand their coverage and to talk with their providers about their coverage and seek support and and resources from your care providers, financial teams. All hospitals have financial access service teams who can meet with you and talk with you about your coverage and anticipate out-of-pocket expenses based on the treatment regimen that is recommended.
24:17 --> 24:46Dr. Battaglia That often doesn't happen at the start of someone's therapy or during the planning phases of therapy. Cancer diagnoses. And it's only until someone's experiencing significant financial burden that it becomes an issue. And so I guess my message to patients who have a cancer diagnosis is talk to your providers about this, understand your plan and your deductibles, and seek, support, to plan ahead.
24:46 --> 25:26Dr. Winer And, and those expenses that that patients in cancer and patients and families encounter include both co-pays. But also as you were talking about out of pocket expenses and for that matter, income loss. Because, not only are people paying for parking and transportation and child care and all sorts of other things, but there are times when both a person with cancer and their family members, have to leave their job or work less in order to provide that care, or, and receive that care.
25:26 --> 25:41Dr. Winer And it it's it's huge and and of course financial toxicity or financial hardship from medical treatment is one of the major causes of bankruptcy in the United States.
25:41 --> 26:06Dr. Battaglia It's astounding actually. It's really just when you look at the numbers, I remember when I was training and practicing in Boston at the Safety Net Hospital where I, you know, practiced. We often said a cancer diagnosis was not the worst thing that our patients were dealing with. They had a lot of other burdens, and some of them were were financial burdens.
26:06 --> 26:30Dr. Battaglia And they had to make really difficult decisions around whether or not to miss work and therefore miss a paycheck because they were hourly wage to get their cancer treatment or to go to work so they could put food on their table for their family. And these are real decisions and choices. Patients who are eligible for subsidies have to make.
26:30 --> 26:59Dr. Winer And, you know, within cancer to make this even more stark, the newest treatments, some of the most effective, the best treatments are not only the most expensive treatments, but they're treatments that often, require people to take a little more time off from work. And require more assistance from family members to get through the therapy. Which just makes the burden even greater.
26:59 --> 27:10Dr. Winer And, and, and ironically, as we get better and better treatments and more expensive treatments, the disparities just continue to grow.
27:10 --> 27:40Dr. Battaglia The same is true for those with later stages to see diseases, right? Because they're basically on chronic therapy. That doesn't end, I think there was a recent study that I looked at that looked, out of pocket expenses in the first six months after diagnosis of breast, colorectal or lung cancer screening and can you take a guess about how much per month out-of-pocket expenses in the first six months after cancer diagnosis?
27:40 --> 27:47Dr. Winer Oh, I can only, imagine that it it must run into the thousands.
27:47 --> 28:00Dr. Battaglia Well, in this particular say, it was five, $600 a month overall for those diseases in all stages. But when you looked across diseases and stage, you know, the later stages, diseases had the highest burden. So.
28:00 --> 28:27Dr. Winer Sure. Yeah. So I'm, I'm accurate for the, for unfortunately the, the the the individuals who are the sickest and you know for people living on fixed incomes, for people who are not in high paying jobs, five, $600 a month is is a huge amount of money. So, Tracy, thanks.
28:27 --> 28:32Dr. Battaglia I appreciate the the, opportunity to talk about this really important topic.
28:32 --> 28:57Announcer Doctor Tracy Battaglia is a professor of medicine and medical oncology at the Yale School of Medicine. If you have questions, the address is Cancer answers@yale.edu and past editions of the program are available in audio and written form at Yale Cancer center.org. We hope you'll join us next time to learn more about the fight against cancer funding for Yale Cancer answers is provided by smile oh Cancer Hospital.

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