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In April 2020, the U.S. unemployment rate reached an all-time high of 14.7 percent. By May 28, more than 40 million people in the U.S. had filed for unemployment insurance as the COVID-19 pandemic led to the shuttering of business after business.
In an employer-based healthcare system, the repercussions of this massive unemployment can have a devastating effect on the ability to obtain healthcare services. Although it is too early to accurately gauge the long-term impact on healthcare of the unemployment brought on by recent business closures, the Kaiser Family Foundation estimated in May 2020 that nearly 27 million people in the U.S. may have lost employer-sponsored insurance since the dawn of COVID-19.
Before the Pandemic
To understand how this widespread loss of insurance may affect individual patients, it is helpful to know the state of financial need among patients before the pandemic hit. The arrival of COVID-19 took place against a backdrop of skyrocketing healthcare costs. Today’s consumers are expected to pay an increasing amount of their healthcare costs out of pocket, with rising co-pays, coinsurance, and deductibles resulting in fewer and fewer people able to fully afford their care.
Physicians and researchers have long observed that a patient’s insurance status can affect the quality of care they receive and their ultimate outcomes. To better understand how coverage status can influence the treatment of patients with cancer, researchers conducted a review of studies of health insurance coverage disruptions and cancer care published between 1980 and 2019.
The results of that review, conducted before the COVID-19 pandemic began and published in the Journal of the National Cancer Institute, found that health insurance coverage disruptions—defined as gaps in coverage or transitions between types of coverage or between specific health insurance plans—are common and adversely associated with the receipt of cancer care and survival.
The extent of that association is jarring. Researchers determined that from 4.3 percent to 32.8 percent of the adults in the reviewed studies experienced coverage disruptions. These people were less likely to receive cancer prevention or screening (31 percent), less likely to receive treatment (13.8 percent), and less likely to receive end-of-life care (10.3 percent). They were also more likely to be diagnosed at a later stage (44.8 percent) and have a lower rate of survival (20.7 percent), leading the study’s authors to conclude, “Lack of health insurance coverage is one of the strongest predictors of poor cancer outcomes in the United States.”
Currently compounding this situation is the fact that many people have gone without preventive cancer care during the pandemic. A report in April 2020 found that cancer scans are down precipitously as the pandemic continues to disrupt routine care. The report, based on medical claims data, found that diagnostic panels and cancer screenings typically performed during annual physician visits fell by as much as 68 percent nationally.
In May 2020, the electronic medical records vendor Epic reported that appointments for cervix, colon, and breast cancer screenings were down between 86 percent and 94 percent in March 2020, compared to average volumes in the three years before the first confirmed case of COVID-19 in the U.S. As many people emerge from the pandemic out of work and uninsured, there is the danger that they will not resume routine care, leading to current cancers remaining undiagnosed until they manifest at a later stage.
Rifeta Kajdic, the oncology program manager at St. Luke’s Cancer Institute in Boise, Idaho, and a member of the ACCC Financial Advocacy Network (FAN) Advisory Committee, says projections of large numbers of newly uninsured patients will manifest in increased demand for financial aid. “The pandemic has caused a lot of fallout for patients who are in the middle of treatment, but who are now without insurance due to being laid off or furloughed,” says Kajdic. “We anticipate a surge of patients who need serious assistance, and there will be a higher demand for financial advocates to find resources. At the same time, resources will likely be more limited due to the pandemic’s economic fallout.”
A survey conducted by the American Cancer Society Cancer Action Network of 1,200 cancer patients and survivors between March 25 and April 8, 2020 indicates that patients are under increasing financial strain to pay for their treatment. Nearly 4 in 10 (38 percent) survey respondents say COVID-19 is having a notable effect on their ability to afford their care, due mostly to reduced work hours. Of the respondents who report that they or a family member living with them has lost a job, 43 percent had employer-sponsored coverage. Of those who report that they or a family member had their hours reduced, 58 percent had employer-sponsored health insurance.
In her capacity, Kajdic manages oncology patient financial advocates across five sites operated by St. Luke’s. She says the healthcare system employs 19 financial advocates across those sites, totaling 15 FTEs. “At all sites combined, we might see about 400 new patients a month,” says Kajdic. “We meet with an average of 70 patients per week. Demand for our services is only increasing, and we expect it to increase a lot more. Already, the resources that are available are being pulled in all directions.”
ACCC’s Financial Advocacy Network (FAN) helps multidisciplinary teams step up to these challenges with education and resources needed to provide financial services to patients and their families. FAN’s Financial Advocacy Boot Camp delivers training modules that increase advocates’ ability to maximize insurance coverage and external assistance, and ACCC’s Patient Assistance and Reimbursement Guide contains directions for enrolling patients in financial assistance programs.