VOLUME
32
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NUMBER
19
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JULY
1
2014
JOURNAL OF CLINICAL ONCOLOGY
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Policy Decisions Have Consequences: Sometimes Unintended Ones Gail R. Wilensky, Project HOPE, Bethesda, MD See accompanying article on page 2025
The article1 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.2 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.3 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.4 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 al1 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 al1 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.5 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, 1994
© 2014 by American Society of Clinical Oncology
clear evidence in Massachusetts, that young people, especially males, were likely to remain uninsured. Aizer et al1 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.6 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.7 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, Vol 32, No 19 (July 1), 2014: pp 1994-1995
Downloaded from jco.ascopubs.org on May 17, 2015. For personal use only. No other uses without permission. Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
Editorial
smarter policies than are in place at present. It may also be helpful to have as many specific outreach programs in place as possible to help reach this particular population although the administration seems to be doing as much as they can in this regard. What Aizer et al1 fail to recognize is that at least one important reason the cost of insurance is so high for young purchasers of health insurance is the result of a deliberate policy decision to assist older purchasers using a budget neutral strategy. To the extent that their concern is regarded as a serious one, it indicates the need to reconsider current policies. The most direct cause of the high cost of insurance for young purchasers is the policy decision to limit the variation in insurance premiums to three to one even though the differential in premiums costs that is justified in actuarial terms is five to one. This was done to limit the cost that older, pre-Medicare purchasers face but it means that young purchasers, who have shown more reluctance to purchase insurance even when it is made available to them on a subsidized basis, face higher premiums than they would otherwise. The requirement to purchase comprehensive coverage also adds to the cost and is an issue for all insurance purchasers. The wisdom and equity of having younger purchasers subsidize the cost for older purchasers of insurance in the exchange should at least be reconsidered— especially given the historic difficulty in getting the so-called young invincibles to put out their own money to buy insurance. Their current low rate of purchase should not come as a surprise given the relatively small penalties for not having insurance at least early on as well as the knowledge that anyone not purchasing insurance will not be subject to discrimination or higher charges later, even if they have high expected use when they purchase insurance. The political challenge of reducing the current cross subsidies for the pre-Medicare population coming from the young will be formidable, and adding more funds for subsidizing the young purchasers without reducing these cross subsidies will also be formidable, which means that undoing this decision will not be easy. The question of
whether the current trade-off between providing more comprehensive coverage and keeping coverage affordable is at the right point may also require further deliberation—the more comprehensive the coverage, the more expensive the policy. As is true for many aspects of public policy, assessing the value of deliberate policy decisions is relatively straightforward—in this case, the desirability of lowering the premiums of the pre-Medicare population who would otherwise face high premiums because of their high expected use and their greater incidence of various types of disease, including cancer. What is frequently harder—in this case, the increased challenge of getting already reluctant younger people to enroll—is assessing the unintended consequences likely to result and weighing the trade-off between the desired and the unintended consequences. It may be more than time to consider the latter. AUTHOR’S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
The author(s) indicated no potential conflicts of interest. REFERENCES 1. Aizer AA, Falit B, Mendu ML, et al: Cancer-specific outcomes among young adults without health insurance. J Clin Oncol 32:2025-2030, 2014 2. Wilensky GR, Berk M: Poor, sick and uninsured. Health Affairs 2:91-95, 1983. http://content.healthaffairs.org/content/2/2/91.full.pdf⫹html 3. Kronick R, Health Services Research: Health Insurance Coverage and Mortality Revisited. 2009. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2739025/ 4. Wikipedia: Patient Protection and Affordable Care Act. http://en.wikipedia.org/wiki/ Patient_Protection_and_Affordable_Care_Act 5. Wikipedia: Massachusetts Health Care Reform. http://en.wikipedia.org/wiki/ Massachusetts_health_care_reform 6. Office of the Assistant Secretary for Planning and Evaluation: 2013 Poverty Guidelines. http://aspe.hhs.gov/poverty/13poverty.cfm 7. Wilensky GR: Room for Debate: Deterring, and Losing, Those Who Are Needed. http://www.nytimes.com/roomfordebate/2014/03/20/obamacares-fouryear-checkup
DOI: 10.1200/JCO.2014.55.6712; published online ahead of print at www.jco.org on June 2, 2014
■ ■ ■
www.jco.org
© 2014 by American Society of Clinical Oncology
Downloaded from jco.ascopubs.org on May 17, 2015. For personal use only. No other uses without permission. Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
1995
32
䡠
NUMBER
19
䡠
JULY
1
2014
JOURNAL OF CLINICAL ONCOLOGY
E
D
I
T
O
R
I
A
L
Policy Decisions Have Consequences: Sometimes Unintended Ones Gail R. Wilensky, Project HOPE, Bethesda, MD See accompanying article on page 2025
The article1 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.2 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.3 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.4 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 al1 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 al1 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.5 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, 1994
© 2014 by American Society of Clinical Oncology
clear evidence in Massachusetts, that young people, especially males, were likely to remain uninsured. Aizer et al1 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.6 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.7 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, Vol 32, No 19 (July 1), 2014: pp 1994-1995
Downloaded from jco.ascopubs.org on May 17, 2015. For personal use only. No other uses without permission. Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
Editorial
smarter policies than are in place at present. It may also be helpful to have as many specific outreach programs in place as possible to help reach this particular population although the administration seems to be doing as much as they can in this regard. What Aizer et al1 fail to recognize is that at least one important reason the cost of insurance is so high for young purchasers of health insurance is the result of a deliberate policy decision to assist older purchasers using a budget neutral strategy. To the extent that their concern is regarded as a serious one, it indicates the need to reconsider current policies. The most direct cause of the high cost of insurance for young purchasers is the policy decision to limit the variation in insurance premiums to three to one even though the differential in premiums costs that is justified in actuarial terms is five to one. This was done to limit the cost that older, pre-Medicare purchasers face but it means that young purchasers, who have shown more reluctance to purchase insurance even when it is made available to them on a subsidized basis, face higher premiums than they would otherwise. The requirement to purchase comprehensive coverage also adds to the cost and is an issue for all insurance purchasers. The wisdom and equity of having younger purchasers subsidize the cost for older purchasers of insurance in the exchange should at least be reconsidered— especially given the historic difficulty in getting the so-called young invincibles to put out their own money to buy insurance. Their current low rate of purchase should not come as a surprise given the relatively small penalties for not having insurance at least early on as well as the knowledge that anyone not purchasing insurance will not be subject to discrimination or higher charges later, even if they have high expected use when they purchase insurance. The political challenge of reducing the current cross subsidies for the pre-Medicare population coming from the young will be formidable, and adding more funds for subsidizing the young purchasers without reducing these cross subsidies will also be formidable, which means that undoing this decision will not be easy. The question of
whether the current trade-off between providing more comprehensive coverage and keeping coverage affordable is at the right point may also require further deliberation—the more comprehensive the coverage, the more expensive the policy. As is true for many aspects of public policy, assessing the value of deliberate policy decisions is relatively straightforward—in this case, the desirability of lowering the premiums of the pre-Medicare population who would otherwise face high premiums because of their high expected use and their greater incidence of various types of disease, including cancer. What is frequently harder—in this case, the increased challenge of getting already reluctant younger people to enroll—is assessing the unintended consequences likely to result and weighing the trade-off between the desired and the unintended consequences. It may be more than time to consider the latter. AUTHOR’S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
The author(s) indicated no potential conflicts of interest. REFERENCES 1. Aizer AA, Falit B, Mendu ML, et al: Cancer-specific outcomes among young adults without health insurance. J Clin Oncol 32:2025-2030, 2014 2. Wilensky GR, Berk M: Poor, sick and uninsured. Health Affairs 2:91-95, 1983. http://content.healthaffairs.org/content/2/2/91.full.pdf⫹html 3. Kronick R, Health Services Research: Health Insurance Coverage and Mortality Revisited. 2009. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2739025/ 4. Wikipedia: Patient Protection and Affordable Care Act. http://en.wikipedia.org/wiki/ Patient_Protection_and_Affordable_Care_Act 5. Wikipedia: Massachusetts Health Care Reform. http://en.wikipedia.org/wiki/ Massachusetts_health_care_reform 6. Office of the Assistant Secretary for Planning and Evaluation: 2013 Poverty Guidelines. http://aspe.hhs.gov/poverty/13poverty.cfm 7. Wilensky GR: Room for Debate: Deterring, and Losing, Those Who Are Needed. http://www.nytimes.com/roomfordebate/2014/03/20/obamacares-fouryear-checkup
DOI: 10.1200/JCO.2014.55.6712; published online ahead of print at www.jco.org on June 2, 2014
■ ■ ■
www.jco.org
© 2014 by American Society of Clinical Oncology
Downloaded from jco.ascopubs.org on May 17, 2015. For personal use only. No other uses without permission. Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
1995
