Cancer Patients May Fare Better Under Obama Plan, Many Experts Believe

Source: Medscape Medical News
By: Roxanne Nelson

October 15, 2008 — As the United States election campaign moves into its final weeks, proposals from both presidential candidates have come under intense scrutiny, including their extensive plans for reforming the current healthcare system. Although it is difficult to predict what changes might actually transpire once the election is over, many experts speculate that cancer patients may fare better under the Democratic proposal, at least as far as healthcare coverage is concerned.

The agendas of John McCain (R-Arizona) and Barack Obama (D-Illinois) would initiate dramatic changes in the US healthcare system, and take it in very different directions. But a key aspect of the Obama plan is its guarantee that insurance companies will not be permitted to discriminate against anyone because of a pre-existing condition, such as cancer.

"The Obama plan has a guaranteed eligibility provision that requires insurers to cover pre-existing conditions," said Anne Royalty, PhD, associate professor of economics at Indiana University-Purdue University, in Indianapolis. "The National Health Insurance Exchange proposed in the Obama plan also requires that the premiums of the plans in the exchange cannot depend on health status. Both of these provisions will benefit patients in poorer health or with pre-existing conditions, including cancer patients," she said.

These provisions will benefit patients in poorer health or with pre-existing conditions, including cancer patients.

Harold Pollack, PhD, associate professor at the University of Chicago School of Social Service Administration and faculty chair of the Center for Health Administration Studies, in Illinois, agrees. "The McCain plan encourages people to move into the free market, which may benefit some," he said. "But there are a whole variety of structures in the McCain plan that are ill suited for people with chronic needs, such as cancer patients. It would allow or even encourage the loosening of state regulations that currently protect people with chronic illnesses."

A number of attempts to revamp healthcare have failed during the past half century, with the last major push taking place in 1993/94, during the first term of President Bill Clinton. Except for the changes in Medicare that were initiated in 2003, healthcare reform has not seriously been approached again until now. Renewed interest in tackling healthcare issues has been spurred on by many factors, including the large number of uninsured Americans, estimated at close to 47 million, and the increasing costs of care. Even for Americans with insurance, rising premiums, copays, and coinsurance are making healthcare less affordable.

What the Candidates Say About Access to Care

Although the American Cancer Society (ACS) has not officially endorsed either healthcare plan, the ACS-Cancer Action Network (ACS-CAN) asked the presidential candidates to discuss their respective positions on cancer research, prevention, and treatment issues.

Addressing the issue of access to care, the ACS-CAN put forward to the following question to the candidates: What steps will you take to ensure that all Americans have access to the full continuum of quality cancer care, including prevention and early detection through treatment and follow-up care?

Sen. McCain responded that his reforms would give consumers "a level of health-insurance-coverage portability never before seen," and allow them to maintain continuous coverage throughout their life. His plan would give individuals tax credits to purchase insurance directly, believing that this will open the insurance market to competition. Having an individual health plan, as opposed to one that is employer-sponsored, would allow individuals to stay with the same plan and not have to switch providers every time they change jobs.

Sen. McCain also stated that everyone with a pre-existing condition, such as cancer, would be guaranteed an affordable option. Individuals with pre-existing conditions who are unable to get access to affordable healthcare could join their state's Guaranteed Access Plan (GAP), and assistance would be available for those requiring help in purchasing their GAP coverage. He would also work with insurers and consumers to ensure that prevention and maintenance care are included as part of health plans.

Sen. Obama replied that he believes "that every American has the right to affordable, comprehensive, and portable health coverage." Coverage would be guaranteed for every American, regardless of pre-existing conditions, and this would be accomplished through partnerships among employers, private health plans, the federal government, and the states. By modernizing the healthcare system to contain spiraling costs and improve the quality of patient care, Sen. Obama said that his plan will save a typical American family up to $2500 every year in medical expenses.

He also said that he will ensure that evidence-based treatments are widely adopted by rewarding providers for achieving performance thresholds on outcome measures. Individuals will be able to easily compare health plans because his agenda would require hospitals and providers to collect and publicly report measures of healthcare costs and quality, including data on preventable medical errors, nurse staffing ratios, hospital-acquired infections, and disparities in care.

The Plans Up Close

The candidates agree on a number of aspects of healthcare reform, including initiating pay for performance, malpractice reform, and increasing funding for cancer research. Sens. Obama and McCain both propose platforms in which healthcare continues to be structured around private insurance markets, with public programs in more of a supporting role. But that is where the similarity ends, especially regarding healthcare coverage.

The McCain plan represents a dramatic shift from traditional group insurance, instead embracing market forces and promoting individually purchased insurance plans. The core of the agenda is to alter the current tax code to one in which employees would have to pay taxes on the health-insurance premiums that are provided and paid for by their employers. Tax credits of $2500 per individual and $5000 per family would be issued to increase the incentive to move to an individual insurance plan. To further promote competition and health-plan options, the McCain plan would allow health insurance to be sold across state lines.

Conversely, the Obama plan is focused on offering affordable, high-quality universal coverage through a mix of private and expanded public insurance, and includes insurance-market regulation. The key point of this agenda is that employers will be required to either offer workers insurance or pay a tax that will help finance coverage for uninsured individuals. Some small businesses would be exempt from the mandate, and others would receive subsidies. The Obama plan would mandate coverage for children, create a new government health plan, and create a national health-insurance exchange.

Both the Republican and Democratic healthcare reform agendas tackle a variety of issues, and experts agree that both plans have merit and downsides. However, the general consensus among experts surveyed by Medscape Oncology is that Sen. Obama's plan offers more safeguards for high-risk individuals, including cancer patients and survivors.

Loss of Employer-Sponsored Plans

The current tax-free status of employer-sponsored health benefits has been criticized as being discriminatory and regressive, and some analysts feel that it encourages people to buy excessive coverage. But more than 60% of Americans are covered under an employer-provided system, and the Health Insurance Portability and Accountability Act of 1996 prohibits employer-sponsored health plans from discriminating against employees with pre-existing conditions.

Individual health-insurance markets do not have the same protections and are subject to state regulations. A 50-state survey of insurance commissioners released in July 2008 by USA Families revealed that the majority of states are not prohibited from denying health coverage to people with pre-existing conditions. In fact, only 5 states explicitly prohibit insurance companies from selecting only the healthiest consumers and excluding everyone else. In 35 states and the District of Columbia, there are also no limits on how much insurers can raise premiums on the basis of an individual's health status. Many experts feel that the McCain plan would accelerate the disintegration of employer-provided coverage, and thus leave people with pre-existing and chronic conditions, such as cancer, with few options.

"The McCain plan is a roll of the dice, and while it's not clear what its effects will be, it is possible that it could lead to many employers dropping their existing health-insurance policies," Jonathan Oberlander, PhD, associate professor of social medicine and health policy and management at the University of North Carolina-Chapel Hill, told Medscape Oncology. "If that happens, workers would have to find coverage in the individual insurance market. For cancer patients, that is a difficult market because premiums are based on insurers' assessments of medical risk. So for some cancer patients, they could be worse off under the McCain plan if their employers drop their coverage."

Dr. Oberlander believes that the Obama plan would clearly be a better option for cancer patients, since it would regulate the insurance market to prevent medical underwriting and discrimination on the basis of a patient's medical status. "It would also create new public and private options for the uninsured, so Americans who are now medically uninsurable — including many cancer patients — would have access to coverage," he added.

Americans who are now medically uninsurable — including many cancer patients — would have access to coverage.

David Blumenthal, MD, professor of healthcare policy at Harvard Medical School and director of the Institute for Health Policy at Massachusetts General Hospital, in Boston, points out that anything that undermines employer-sponsored insurance is a threat to cancer patients who are currently employed or dependents of employed people. "The most salient aspects of the McCain plan are its potential effects on the ability of people with chronic illnesses, such as cancer, to get affordable health insurance with good benefits," said Dr. Blumenthal. "The creation and maintenance of risk pools that are accessible to chronically ill Americans is critical to cancer victims and survivors, and the most important source of risk pools in the United States is employer-sponsored insurance."

Dr. Blumenthal explained that the McCain plan would reduce the number of employees with employer-sponsored insurance by about 20 million, among whom there will certainly be cancer victims and survivors. "These individuals will have considerable difficulty finding affordable insurance in the individual market," he said. "And if they do find insurance, it will certainly cost them more than the tax credits offered and more than they would have paid out-of-pocket in the workplace."

A state-by-state analysis conducted by the nonprofit, nonpartisan Economic Policy Institute, which specifically examined the potential effect of the McCain policy on employer-sponsored health insurance, found that between 11 and 27 million people would lose their coverage. The percentages varied among states, but the Washington, DC–based think tank found that it averaged out to a loss of coverage for 19 million people if the tax exclusion were to be removed.

A Commonwealth Foundation analysis of the presidential platforms noted that "McCain's tax credits would not change the medical underwriting practices in the individual market that make it difficult for older people or those with health conditions to find affordable coverage." The Pennsylvania-based nonpartisan public policy research and educational institute also noted that without any regulations against risk selection and the imposition of benefit standards, "the value of McCain's tax credits would vary significantly based on age, health status, gender, and geographic differences in the cost of healthcare."

It represents a philosophical advance over many other healthcare proposals.

The Urban Institute, a Washington, DC–based nonpartisan think tank, analyzed the McCain healthcare proposal and noted that "it represents a philosophical advance over many other healthcare proposals." However, they also found that the McCain healthcare proposal "would make insurance coverage less accessible and affordable for those with high healthcare needs." Although the plan would increase coverage for individuals that are currently uninsured, it would also reduce the numbers who are already covered by employers, leaving about the same number of people without insurance.

Under Sen. McCain's proposal, people who are unable to obtain health insurance on the private market would be able to do so through state GAP programs, and federal funding would be used to expand these high-risk pools.

But state-funded GAP programs have not been very effective and they have a poor track record, Dr. Pollack told Medscape Oncology. Currently, they cover fewer than 200 000 people in 34 states, and lack sufficient funding.

"Senator McCain has proposed only $7 to $10 billion to subsidize these high-risk pools, and that is not nearly enough to cover the large number of people who may need it," said Dr. Pollack. "We would have to see a plan with more details and much better financing before we can be confident that these people would be covered."

Pie in the Sky

Although numerous analysts and economists have grappled over and dissected the plans of both candidates, neither is concrete and in its final form. Basically, they are campaign promises, commented Joseph Antos, PhD, a scholar in healthcare and retirement policy at the American Enterprise Institute, in Washington, DC, and a commissioner of the Maryland Health Services Cost Review Commission, in Baltimore.

Politicians like to build castles in the air, and it is unlikely that any sort of giant healthcare reform is actually going to happen right away.

"Politicians like to build castles in the air, and it is unlikely that any sort of giant healthcare reform is actually going to happen right away," he said. "And it's not just because of the financial crisis, but simply because healthcare reform is expensive and that has always been the problem."

"What we are hearing now are campaign slogans, and one has to think how these plans will actually work in reality," said Dr. Antos. "Healthcare is not going to change in just 1 swift move from Congress."

For example, some states have previously attempted to equalize healthcare coverage and the result was that some insurers left the state. Sen. Obama's plan is focused on expanding coverage and tightening federal oversight of the insurance industry but, at the same time, does not address the core economic incentives that drive healthcare spending.

"Neither candidate has laid out a comprehensive roadmap," said Dr. Antos. "We do need changes in our healthcare system, and we've known that for decades. It would be easier if it wasn't for the current financial crisis. But healthcare costs are expected to continue increasing, and both candidates are going to have to deal with that."

Regardless of the election outcome, Dr. Antos cautions that we shouldn't expect any changes until at least 2010. "It's just not going to be possible to have sweeping health reform in the first year," he said. "But one thing we can be sure of is that whoever wins the election is going to have his work cut out for him."