Cancer Care and the Affordable Care Act (ACA)
Health Insurance Marketplaces
On October 1, 2013, state-based health insurance marketplaces (also known as insurance exchanges) opened for enrollment. Created under the Affordable Care Act (ACA), the exchanges are designed for the uninsured, people who buy their own coverage, and those whose employer-provided coverage is too expensive or lacks needed benefits.
The second open enrollment period occurred November 15, 2014, through February 15, 2015. A extra enrollment period also took place March 15 to April 30, 2015, providing an opportunity for those confused by requirements to avoid a portion of the 2015 fee for non-coverage. Over 10 million people have enrolled, with 85% receiving advance premium tax credits (reported by the Kaiser Family Foundation).
As of 2015, 34 states have defaulted to federally facilitated marketplaces. People insured through health insurance exchange plans in these states stand to be affected by the June 2015 Supreme Court decision regarding federal subsidies. (For details on state impacts, see Kaiser Family Foundation graphic)
Supreme Court Decisions on the Affordable Care Act (ACA)
On June 28, 2012, the Supreme Court upheld the central component of the Affordable Care Act agreeing that the requirement for nearly all Americans to secure health insurance is permissible. The vote came down to a 5-4 decision, with Chief Justice John Roberts providing the swing vote for the majority.
On June 25, 2015, the U.S. Supreme Court issued their decision in the highly anticipated King v. Burwell case, ruling that the more than 6 million people currently purchasing insurance through a federal exchange can continue to access subsidies. In a 6-3 decision, Chief Justice Roberts’ Court concluded that “Congress passed the Affordable Care Act to improve health insurance markets, not destroy them. If at all possible, we must interpret the Act in a way that is consistent with the former, and avoids the latter.”
For more information, read our ACCCBuzz blog post: King V. Burwell: Federal Health Insurance Subsidies Upheld for Patients (June 25, 2015)
Read previous ACCCBuzz blog posts on ACA and Health Exchanges
- CANCERSCAPE—ACA's Impact on the Frontline of Care (March 24, 2015)
- With the Midterm Elections Behind Us, What Lies Ahead for Healthcare in 2015 (November 25, 2014)
Here are brief highlights of the Affordable Care Act (ACA):
Potential Benefits to Cancer Patients
- Patients/survivors with existing insurance will have more adequate coverage, e.g., no lifetime limits, fewer annual limits, no rescissions, retiree reinsurance, first dollar coverage of screenings and other preventive services.
- Subsidized high-risk pools at age adjusted standard premiums.
- Improved information about value of available options; more standardized information. Insurers have to compete more on basis of price and service than on risk selection.
- Group health plans and health insurance issuers offering individual or group health insurance products required to cover routine patient costs associated with approve clinical trials. (View fact sheet on ACA Clinical Trials Coverage.)
Some Potential Challenges and Drawbacks
- Some may still find insurance unaffordable especially if costs are not contained much; state-based exchanges may be too small to create sustainable risk pools and states may not provide aggressive oversight needed to ensure fair competition; employer wellness incentive programs may penalize employees for poor health status.
- Plans increasingly limit access to drugs through specialty tier placement and cost-sharing requirements.
Physician Quality Reporting and Value-Based Purchasing (VBP)
- Quality Reporting: Makes Physician Quality Incentive Program (PQRS) permanent.
- Imposes 1.5 percent penalty in 2015 for failure to report successfully; penalty increases to 2 percent in subsequent years.
- Beginning 2011, allows registry reporting through a Maintenance of Certification program operated by a specialty body of the Board of Medical Specialties.
- Requires timely feedback on likelihood of receiving incentive payment and an appeals process.
- Requires plan for Scretary to integrate clinical reporting with electronic health records (EHR).
- Physician Feedback Program: Requires confidential feedback reports to physicians comparig their performance on quality and efficiency to peers.
- VBP for Physicians: Adjusts 1 percent of physician payment based on value index (quality and efficiency) beginning in 2015.
- Requires that a hospital complete a community needs assessment once every three years.
- Requires hospitals to adopt and publicize a financial assistance policy.
- Prohibits billing patients who qualify for financial assistance the top rates.
- Prohibits a hospital from taking extraordinary collection actions if the hospital has not made reasonable efforts to notify patients of its financial assistance policy.