Understanding health insurance options in the United States can be incredibly confusing, particularly in light of the ever-changing expansions under the Affordable Care Act (ACA). Healthcare delivery varies widely depending on whether a person has public insurance, private insurance, or is uninsured, and these differences in access can greatly impact health outcomes, particularly when a person has cancer.
According to Amy Davidoff, PhD, MS, social and behavioral scientist administrator at the National Cancer Institute, knowing some basics about health insurance can help patients to feel more like active members of their own care teams.
“Health insurance coverage is important and necessary,” she said at the 2022 Summit on Cancer Health Disparities in Seattle, WA. “But it’s not nearly sufficient, and it’s not all created equal.”
What Difference Does Insurance Make?
“Unlike some countries that have national health insurance, or at least ensure that everyone has access to health insurance, we tend to use health insurance as a kind of policy lever,” said Dr. Davidoff.
Simply put, some people in the United States have more access to better health insurance than others, so it’s important to pay attention to how insurance is used in our country, she said.
From the patient side, insurance provides financial protection at the point of care. This financial support, in addition to negotiated rates, can save patients money as well as worry and distress that accompany financial concerns.
When it comes to recommended cancer screenings like Pap smears, mammograms, and colorectal cancer screenings, uninsured people are significantly less likely to undergo screenings than people with private or public insurance (like Medicare and Medicaid).
People with private insurance are the least likely to have a late-stage cancer diagnosis, as these patients typically have their cancer diagnosed at an earlier stage when it’s easier to treat. In addition, privately insured patients are more likely to receive the recommended treatment for their cancer when compared with people with other types of insurance.
Public insurance options vary, and while public insurance does have benefits, it’s not without its drawbacks. For example, Medicaid provides a high level of financial protection, but not a lot of provider access. Medicare has better provider access but subpar financial protection compared with Medicaid. However, Medicare in combination with private insurance offers high levels of both financial protection and provider access.
It’s clear that insurance coverage does matter in the US healthcare system, but all insurance is not the same. In fact, differences in insurance coverage and benefits highlight the many widespread disparities in the country and point to the fact that private insurance typically translates to a better patient experience.
Health Insurance Expansions Under the ACA
The ACA was designed to improve healthcare quality, accessibility, and affordability in the United States. After its implementation, several expansions to the ACA were put in place, most notably, the expansion of Medicaid.
The initial goal of this expansion was to provide uniform Medicaid eligibility for all adults under the age of 65 years with income under 138% of the federal poverty level. This included people without dependent children, who were typically excluded from the Medicaid program before the ACA. According to Dr. Davidoff, this was particularly beneficial for people between the ages of about 40 to 64—a group in which cancer incidence is increasing—with grown children who had moved out of the house.
“But unfortunately, the mandatory nature of the expansion was undermined with the Supreme Court decision in 2012, making it a voluntary expansion,” she noted. Currently, 39 states, including Washington, DC, have adopted the Medicaid expansion decision, with most holdouts clustered in the Southeast (as well as Texas, Kansas, Wyoming, South Dakota, and Wisconsin).
ACA health insurance expansions also impacted private insurance. Insurance Marketplaces were established in 2014 as centralized, state-specific sources to purchase individual insurance plans. Plans in the Marketplace are presented in 4 health “metal” categories: Bronze, Silver, Gold, and Platinum.
These stepwise categories do not refer to the quality of care delivered, but only to how much a patient covers out of pocket, and how much is covered by their insurance plan. For example, the insurance company and patient split cost 60%:40% in a Bronze plan, 70%:30% in a Silver plan, and so on. A Bronze plan has the lowest monthly premium (monthly payment), but the highest costs for care, while a Platinum plan has the highest monthly premium and lowest costs when care is needed.
Income-based premium subsidies (tax credits that can help lower monthly insurance costs), and income-based cost-sharing subsidies (which reduce out-of-pocket spending on Silver plans specifically), also help to curb costs for low- and middle-income patients.
Outside of the Insurance Marketplace, expansions led to the end of exclusions from insurance coverage for preexisting conditions like cancer and increased availability of private insurance plans for workers in larger firms.
Finally, the individual insurance mandate—which was enacted in 2014 and required individuals to purchase minimum essential coverage or face a penalty—is still in place but is no longer enforced.
Effects of the ACA on Insurance Access
“The goal of the ACA was universal coverage, but we knew that was never possible,” said Dr. Davidoff.
However, it did result in a substantial decrease in uninsured patients, due in large part to the expansion of Medicaid and an increase in Medicaid enrollment. “But there remain a tremendous number of people in the US who are still uninsured,” she noted.
In terms of cancer care specifically, more research is needed on the effects of ACA-related coverage, according to Dr. Davidoff. However, research has shown that ACA insurance expansions have led to an uptick in certain cancer screenings, with more patients now being up to date on screening for colorectal cancer. This increase has been particularly noticeable among lower-income individuals and racial, ethnic, and minority groups.
Increases in access to screening have also led to small but important changes in stage at diagnosis; Medicaid expansion has been associated with an increase in early-stage cancer diagnoses and a relative decrease in the proportion of late-stage diagnoses. According to Dr. Davidoff, these changes might be subtle, but they are a crucial step in the right direction in terms of equitable healthcare delivery in the United States.
Although racial/ethnic differences in 5-year survival in patients with advanced-stage cancers do remain, the ACA expansions also reduced differences in the rate of timely treatment (care received in 30 days or less) received by black versus white patients.
“Prior to the expansion, white patients were much more likely than black patients to receive care in a timely manner,” she said. “After the expansion, that gap almost entirely disappeared. It’s a narrow—but important—slice of the picture.”