This year I attended the ASCO annual meeting for the first time but from the comfort of my studio in New York City. I pre-recorded our presentation for our abstract titled “Changes in cancer mortality rates after the adoption of the Affordable Care Act” (1) and eagerly waited for 8 a.m. Friday morning when on-demand sessions would be available for viewing. Sure, there were blips in the website as thousands of oncologists stormed the virtual meeting library but this was an encouraging sign that the enthusiasm to share and learn from the community’s work was not brought down by COVID-19.

I was impressed with the abstracts of the investigators in the same health policy track and especially impressed by the discussion synthesizing all the work by Dr. Devika Das from the University of Alabama. Studies in the track found out-of-pocket costs for patients in the U.S. are sky high for new drugs compared to other developed countries (2), which may contribute to why there are barriers to prescribing targeted therapy for patients even when truly indicated (3). Another study found that multidisciplinary care for lung cancer was associated with higher rates of national guideline-concordant care and survival, thus highlighting the need for better care coordination (4). From these studies, Dr. Das’ takeaway was clear. In order to truly fix health care, there needs to be a two-pronged approach with both health policy and health delivery reform. Access and resources can affect who lives and dies.

Our work on the ACA was the first to show the differential benefit on cancer-specific mortality in states that adopted Medicaid expansion in 2014. In the weeks leading up to the ASCO meeting, reporters have asked our team how this policy saved lives from cancer. Simply, the ACA increased insurance coverage for 20 million people and studies have shown having insurance is associated with early cancer diagnoses, timeliness of care and more treatment options. Copays were eliminated for preventive care such as cancer screening interventions like mammograms and colonoscopies. Pathways for approval of generic versions of expensive drugs and protections for people with pre-existing conditions likely contributed to the benefit as well.

I am from Georgia, a non-expansion state, and attended medical school in rural, middle Georgia but now live in an expanded state. I have seen the heart-breaking stories during my rotations on the wards where an uninsured patient presented with a new diagnosis of breast cancer that had already spread because she was unable to get adequate screening or care in time. The success of the ACA means that we can hear fewer and fewer of these heart-breaking stories — if you live in the right state.

We know that health and health care inequities continue to be a major issue in the United States today. This is evident with the current COVID-19 pandemic as it is disproportionately impacting and killing people of color and of lower socioeconomic status. Sadly, there have been shifts in the political environment with respect to the ACA and many of the provisions that were put in place have been eroded under the current administration. This can undermine the long-term benefit of what our study shows, which would be a tragedy. As oncologists, we know that cancer care shouldn’t be a political issue but unfortunately the debate over health insurance is. We are approaching a crossroads come November and this really represents an opportunity for us to advocate for our patients to improve access for all.

As a daughter of parents who sell insurance policies for a living, the importance of coverage has been ingrained in me since I was very young. But now, this idea is bolstered by data. The bottom line is, the more people who have health insurance, the more lives we can save. I look forward to the ongoing cancer breakthroughs at the next ASCO meeting and hope that patients will have the insurance to be able to benefit from them.

Dr. Anna Lee is completing a proton therapy fellowship in the Department of Radiation Oncology at Memorial Sloan Kettering Cancer Center and was awarded the Allen S. Lichter endowed merit award for the second highest-ranking abstract from the Conquer Cancer ASCO foundation. Her work on the ACA was presented under the mentorship of financial toxicity expert, Dr. Fumiko Chino, attending radiation oncologist at Memorial Sloan Kettering Cancer Center.

References:

1. Lee A, et al. Changes in cancer mortality rates after the adoption of the Affordable Care Act [abstract]. Presented at: 2020 American Society of Clinical Oncology Virtual Scientific Program; May 29-31; online. 
2. Vokinger et al. Launch prices and price developments of cancer drugs in the United States and Europe [abstract]. Presented at: 2020 American Society of Clinical Oncology Virtual Scientific Program; May 29-31; online.
3. Vashistha et al. Barriers to prescribing targeted therapies for NSCLC patients with highly actionable gene variants in the VA National Precision Oncology Program [abstract]. Presented at: 2020 American Society of Clinical Oncology Virtual Scientific Program; May 29-31; online.
4. Osarogiagbon et al. Survival impact of multidisciplinary thoracic oncology care in a regional healthcare system [abstract]. Presented at: 2020 American Society of Clinical Oncology Virtual Scientific Program; May 29-31; online.