The sigh of relief many of us felt when the Supreme Court upheld almost all of the Affordable Care Act is accompanied by disappointment among those seeking to overcome disparities in healthcare among racial and ethnic minorities.
"It is no secret that despite major advances in cancer research, screening, and treatment, not all Americans with cancer have benefited equally," Pallavi Kumar, MD, and Beverly Moy, MD, wrote in a front-page editorial published June 3 in the 2012 ASCO Daily News. "Although there has been a 14 percent decrease in the rate of cancer-related death between the years 1991 and 2004, racial and ethnic minority patients continue to disproportionately die more from cancer compared with their white counterparts, even after adjusting for insurance status and income."
Dr. Kumar is a first-year fellow in hematology and oncology at the Dana-Farber Partners Cancer Center training program in Boston. Dr. Moy is clinical director of the breast oncology program and a medical oncologist at Massachusetts General Hospital in Boston and chairs the ASCO Advisory Group on Health Disparities.
"The oncology community is well aware of the existence of cancer disparities," the editorial said. "However, solutions to improve the equity of cancer care are sorely lacking. Why have we not done more? Where is the outrage?"
They applauded the passage of the Affordable Care Act (ACA), saying it provides an opportunity "to eliminate disparities in cancer care." It includes "provisions that have the potential to expand and improve access, as well as quality of care for the underserved." Heading the list of provisions is "Medicaid expansion to an additional 16 to 20 million individuals" -- the very provision struck down by the Supreme Court, which ruled that states are not obligated to implement the expanded coverage.
"Vulnerable patients will only receive quality cancer care if they have access to it," Kumar and Moy wrote. And even if Medicaid coverage were extended to millions of more individuals, as the ACA had intended, "this expanded coverage might not translate into better outcomes for indigent patients with cancer."
They cite evidence suggesting that cancer patients with Medicaid coverage fare just as poorly as their uninsured counterparts. "This is at least partially due to the fact that almost one-third of oncologists do not accept Medicaid, therefore, the burden of caring for these patients falls on an ever shrinking pool of providers."
Medicaid reimbursement rates are much lower than Medicare rates, which are already below those of most private insurers, the editorial said.
Is this the best that we can do for our most vulnerable patients? Oncologists should remain committed to accepting patients with Medicaid insurance, among others. We look to our legislators and to ASCO to lead efforts to ensure appropriate reimbursement so that providers can continue to care for patients regardless of their ability to pay. We must redouble our efforts to strengthen Medicaid, not abandon it.
Kumar and Moy also urged a shift from research that "merely documents disparities in cancer care" to research that focuses on "real solutions" to improve the equity of cancer treatment. "We must fund studies that implement interventions in vulnerable populations… Lastly, we must strive to improve minority patient participation in clinical trials."
A convincing body of evidence shows that patients of lower socioeconomic status are less likely to receive appropriate oncologic care after a cancer diagnosis. Solutions are needed "to ensure that these patients receive timely care and have concrete survivorship plans," the editorial said. "Early recognition of vulnerable patients with social or cultural barriers to care and implementation of patient navigator programs to help guide patients through treatment are both potential solutions."
The authors also addressed the formidable obstacle imposed by the high cost of many forms of cancer therapy.
We should want to provide all of our patients with excellent care irrespective of their ability to pay. As a community, one of the tasks that lies ahead… is to determine what defines a "benefit," and cost must be a part of that calculus. We look to leaders in the field to refine treatment guidelines, taking into account these cost–benefit analyses. This will facilitate a transition to care that is high quality, cost effective, and equitable.
This is easier said than done, of course, but with the passage of the ACA (and the upholding by the Supreme Court of most of its provisions), "we are poised at the brink of finding and implementing real solutions" that reduce disparities in cancer care. "We urge cancer providers to care for our most vulnerable patients… We urge stakeholders to support Medicaid and prioritize its solvency."
Though the ACA is not perfect, "the entire oncology community should embrace this attempt to improve equity in cancer outcomes and show unified voice in support of health care reform," Kumar and Moy wrote. "Now is the time to put our outrage into action."
I agree. What do you think?