Policy Decisions Have Consequences: Sometimes Unintended Ones

The article that accompanies this editorial describes a well-done study on how outcomes for young adults diagnosed with cancer are affected by lack of health insurance coverage and provides important new evidence that is consistent with earlier studies on the effects of being uninsured. The effects of being uninsured have been analyzed in increasing levels of granularity over the last several decades. In the early 1980s, I and some of my colleagues at what was then called the National Center for Health Services Research (now AHRQ) reported findings from the 1977 National Medical Care Expenditure Survey that showed that people without insurance coverage used about half the care of people with health insurance coverage, irrespective of their health status. Later studies by the Institute of Medicine as well as others have reported increased mortality rates for people lacking health insurance coverage, and this current study reviews findings of increased mortality in patients who have undergone liver transplantation as well as patients with chronic kidney disease and lower cancer screening rates among the uninsured. Being uninsured has also been associated with poor outcomes for several other types of cancer. Thus, it is hardly surprising—but still important to document— that this study reports that being uninsured as a young adult adversely affects the state of cancer at presentation, the use of definitive therapy, and the specific and all-cause mortality rate. The more important part of their discussion is how they relate their findings to the likely results of the Affordable Care Act (ACA) currently being implemented and some policy decisions that may need to be changed or at least reconsidered. The focus of the ACA is on extending coverage to as many of the uninsured as possible and to the extent it is successful at doing so, should improve the use of definitive treatments and favorable outcomes reported by the various studies cited in this current study. Aizer et al raise the concern that several features of the ACA may lead younger people to forgo coverage and thus not have the more favorable outcomes of those who are insured, should they develop a cancerrelated condition. Aizer et al cite the decrease in the number of patients age 19 to 26 years and 27 to 33 years who were insured after the Massachusetts health reform took place as the cause for their concern. While the decrease was small in absolute terms (12.9% and 6.7%, respectively) and difficult to assess in terms of the percentage of currently uninsured in Massachusetts who were previously insured, there is, at the least, clear evidence in Massachusetts, that young people, especially males, were likely to remain uninsured. Aizer et al correctly acknowledge that it is unclear whether what happened in Massachusetts will happen in the rest of the country. There are some important ways in which the Massachusetts reform is similar to the ACA in that it involves state-based insurance exchanges, subsidies for lower income people to help them purchase insurance, and individual and business mandates to push people into buying coverage and providing coverage for their employees. Many of the Massachusetts specifics differ from the ACA—subsidies only up to 300% of the poverty line rather than the 400% in the ACA, a different structure of penalties, and smaller penalties for those receiving subsidies, even after 5 years, among other program differences. The size and scope of the Massachusetts reform is also different—the baseline number of uninsured in Massachusetts was much lower, the requirement for no cost-sharing for preventive services was not present in Massachusetts, the Medicaid expansion was smaller, and the penalty for businesses not providing coverage much smaller than the ACA even though those provisions have been postponed. Despite all of the specific differences between the ACA and the Massachusetts health reform plan, the authors are appropriate in raising their concerns—especially since some of the policy decisions that were made when designing the ACA may end up exacerbating their worries that young males will go without insurance coverage and therefore be negatively affected in the event of a cancer diagnosis. Their concerns center around the high cost of insurance that is being reported in many states for unsubsidized young males in the health insurance exchanges. They recognize that this high cost insurance should not affect young males who have employer-sponsored coverage or those that receive substantial subsidies. They identify young males between 250% and 500% of the poverty line as their main area of concern. I think they are exaggerating the range of income of concern and that the more serious range is for males between 275% and 400%. People at 250% are still receiving substantial subsidies, especially in high-cost areas, and single people at 450% to 500% of the poverty line are able to purchase a plan, even one as high as $3400, if they thought it was important. A single male at 500% of the poverty line, for example, has an income of $57,500 and in all but perhaps the most expensive cities can readily afford the purchase of insurance if he chooses to do so. Convincing young males that it is important to make this purchase—either because having it is so valuable or not having it becomes so expensive requires more or JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 32 NUMBER 19 JULY 1 2014