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Grappling With Healthcare Upheaval

Beth Fand Incollingo @fandincollingo
Published: Friday, Mar 08, 2013

Donna E. Shalala, PhD

Donna E. Shalala, PhD

Oncology leaders are bracing for a host of changes in the healthcare system, not only as a result of the recently upheld insurance reform legislation but also because of continued pressure to control the ever-rising cost of cancer care.

Against this backdrop, Donna E. Shalala, PhD, a former US Secretary of Health and Human Services, is scheduled to open Saturday’s session of the 30th Annual Miami Breast Cancer Conference with a presentation on trends affecting physicians and their patients.

Shalala, who served in President Bill Clinton’s administration, has been president of the University of Miami since 2001. She is a well-known voice in the national conversation about the state of American healthcare, and has shared her opinions about issues including t he Affordable Care Act (ACA), which has significant implications for the oncology community.

Under the ACA, individuals must buy their own insurance if they are not covered through an employer or government program, and are not otherwise exempt from the rule. Starting in 2014, the penalty for not complying will be a “shared responsibility payment,” or tax, payable to the federal government.

Shalala has said she suppor ts the act as a system in which all Americans will share the cost of health insurance. “We need universal coverage so that we share costs and spread risk over larger and larger numbers of people,” Shalala said during a September 2012 panel discussion about the ACA at the University of Miami. She said t hat many Americans are without coverage because they have lost their jobs or were not insured by their employers to begin with, and that, as a result, the rest of the population is absorbing their healthcare costs.

Congress enacted the ACA in 2010 to increase the number of Americans covered by health insurance and decrease the cost of healthcare, but the act was challenged by 26 states, several individuals, and the National Federation of Independent Business. In their lawsuit, the parties argued that the plan was a costly, unconstitutional usurpation of individual rights. However, the US Supreme Court decided in June 2012 to uphold most tenets of the legislation.

While Shalala said that the ACA will help level the playing field in a “fragmented” healthcare system that provides government coverage for some, divergent levels of private coverage for others, and no coverage for many, she acknowledged that its passage will raise new complications. Perhaps the broadest concern, she said, is determining the government’s ideal role in providing healthcare.

“Should the federal government make certain that every American has health insurance through a regulatory system, a subsidy system, or leave it to the states— throw money at them and let them design it?” she asked during the panel discussion.

With the ACA in place, she added, American leader s will have to figure out how to contain healthcare costs, a contentious issue that will be far more difficult to resolve than the problem of arranging universal coverage.

“President Obama was able to get the coverage piece done because it’s putting a trillion dollar s of new money into the system, but getting the deal and the votes on cost containment, given the stakeholders—the whole healthcare system and their lobbyists—is much more complicated and requires bipartisan consensus,” she said.

Promise and Peril in New Law

Like Shalala, leaders in the oncology care and research communities have applauded the potential of the new law to expand access to healthcare but mixed their optimism with a measure of caution over the impact of the legislation.

The American Society of Clinical Oncology (ASC O), the American Cancer Society, and the American Association for Cancer Research were among the organizations that supported the Supreme Court’s decision to uphold the law.

Provisions expected to help patients include free preventive screenings, the elimination of lifetime limits within health insurance plans, and the opportunity for people to get private health insurance regardless of pre-existing conditions. Fears include cost controls that result in the rationing of care and bureaucratic intrusion into decision-making.

Moy et al discussed the anticipated effects of the ACA on the oncology community in an ar ticle that appeared in the 2012 Educational Book that the ASCO published in June at its annual meeting.1

The ACA holds promise, the authors wrote, because it will help close the Medicare “donut hole” gap in prescription drug coverage, important for those taking expensive oral cancer therapies; it will no longer require children who want hospice services to forgo curative services; it gives patients the right to a timely external appeal of coverage decisions; and it prevents insurers from denying coverage for clinical trial costs, which could ultimately increase minority participation in trials.


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