cancer exchanges

Healthcare Reform

How Cancer Patients Are Impacted By Healthcare Reform

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cancer exchanges

Healthcare reform in the U.S. may include a surprising speed bump for some cancer patients, depending on where they live.

When health insurance exchanges go into effect, individuals (and at some point, employers) will be able to pick from private and public insurance plans offered in their state-specific marketplace, and some states could leave cancer patients paying large sums out-of-pocket for expensive medications.

Overall, the Affordable Care Act is a boon for cancer patients, according to Dan Mendelson, CEO and founder of Avalere Health, a strategic advisory company that has extensively researched how cancer patients are affected by health reform.

“A lot of cancer patients were historically denied insurance, but that’s now illegal.” Mendelson told HealthBiz Decoded. “Even if somebody lacks employment, they are going to be able to purchase insurance on the exchange and the early rates that are coming are really very reasonable, so that’s a positive thing.”

But depending on the state they’re in, they may have to pay radically different amounts for the same treatment, or not have access to the best treatment at all, he said.

Many of the plans put biologic and chemotherapeutic drugs on a specialty tier, as Medicare does. When patients under the plans need to access those drugs, they may be asked to pay anything from a nominal fee up to 50 percent of the actual cost of the drug, depending on state rules determining upper limits for out-of-pocket costs.

“For example, the state of New York has said the health insurance plan cannot charge more than $70 for a drug under the medical plan. That’s really great for consumers,” Mendelson said. “But some other states have said ‘you can charge 20 percent of the cost of the drug, or 50 percent’ and that is much more difficult for patients with cancer because they cannot do anything about it.”

“Even if their particular therapy is covered, what will be the patient’s out-of-pocket financial responsibility?” asks Brian Rosen, senior vice president of Government and Public Affairs for The Leukemia and Lymphoma Society (LLS). “That’s a really big problem in many, many states right now: California, Oregon, Connecticut, we’ve seen multiple states come out with expensive, out-of-pocket financial burdens placed on the patents with co-insurances that come up to 20, 30 or up to 50 percent.”

In the Covered California exchange, for example, patients will be responsible for 10-to-30 percent of specialty drugs like Imatinib, a leukemia drug that retails between $6,000 and $7,000 monthly. A 20 percent coinsurance payment would mean $1,200 out-of-pocket every month, compared to the $70 maximum in New York, according to a letter to the California exchange from LLS.

“For someone making $50,000, they have determine whether they’re going to pay their mortgage or going to get access to that therapy that’s going to potentially save their lives,” Rosen said.

Rosen predicts that a healthy patient will join a plan with a low premium in California, then will be diagnosed with non-Hodgkin lymphoma or some other type of leukemia and suddenly will face very high costs. “I suspect in the January – March timeframe of 2014, the administration and Congress are going to hear about these terrible access stories,” which will hopefully lead to more reform, he said.

For now, Rosen and the LLS are trying to educate state insurance commissioners and executive directors of exchanges.

“First of all, patients right now will need to scrutinize their options under the exchange because not all the plans are the same,” Mendelson said. “When they go to purchase insurance, there may be one design that’s better than another. They may be better off with Product A versus Product B in the exchange.”

There may be a need for standardization at the federal level, but that won’t happen in the short term, he said. Any meaningful changes are likely to be processed at the state level.

The focus now is on alerting policymakers to the inconsistencies as soon as possible, Rosen said.

The problem could easily be fixed if more states adopted rules like the one in New York, Mendelson said, but until then it’s important for cancer patients to understand their options thoroughly before enrolling in a plan.

“I do believe a consensus will build over time and it is important for cancer patients to really be engaging in these discussions right now,” Mendelson said.

11 Responses to “How Cancer Patients Are Impacted By Healthcare Reform”

David Sherrard

If the Government really wants to make health care affordable then they need to standardize the language at the federal level so it reads like New York’s language for the biologic and chemotherapeutic drugs. So now if you are on medicare and have cancer and the treatment or drugs are on a speciality tier, What does that mean to the person on medicare who earns at or around the poverty level? Will that person be able to get life saving treatment or will it be back to a choice of eating and paying your utilities or getting the proper or best treatment? This would in reality be a Death Sentence if the cancer patient is not allowed to receive the drugs and treatment that he or she needs because of the price,Is this not what the Obama care is supposed to eliminate?.
This issue needs to be addressed NOW not next year or the following year,Otherwise, OBAMACARE HAS FAILED BEFORE IT CAN EVEN BE PUT FULLY INTO EFFECT!!

Hal Williams

The cost of new cancer drugs is prohibitively expensive and feel the NY plan is much better for out of work people. Think CA should run the numbers now as it would be a simple spread sheet process and save the general public much grief. I am watching a person their mid 20 going through radiation and chemo I know it is a drag on his parents who have retired.

Myrna Reinert

The Great Obama Care. Now that it is here, people are looking over the plan (FINALLY!) as it will apply to then and are finding the faults that everyone ignored. Or rather, stuck their head in the sand thinking it would go away. Now everyone should READ and get what they need so they won’t be paying moré than necessary. It’s a crápula plan so make sure you pick

Myrna Reinert

Page 2 ….. Make sure you pick what you need and what you can afford. This is not inexpensive as you were led to believe. If you work or retired it is very expensive! Be careful and be wise. Good luck!!

george smith

Obamacare not instant answer. need consistency between states ins regs but getting there will be a battle


I am an independent health insurance agent working in rural Kentucky. I am licensed with several health insurance companies and certified for AEP, getting certified with Ky Health Benefits Exchange for ACA. Having worked in insurance since Mar 1990, my services to citizens in KY looking at KHBE comparison and enrollment would be far superior than a librarian who has been certified as a Navigator or In-Person Assister. The training modules for KY Certification were prepared by Easter KY University. Sadly it was full of cartoon characters to keep the reader interested, totally unnecessary for someone who wants to read and comprehend details on this event. Perhaps the worst example of the target market for Navigators/In-Person/Counselors was a multiple choice question on What is an example of HIPPA information? One choice was “pet’s name and date of birth


Please include me on your list for daily, weekly, monthly updates on ACA. Found your article very helpful in understanding ACA changes as they apply to the individual seeking health insurance coverage.

Husband in Katy

Each of us is responsible for our life and our health. No one was promised a free ride for healthcare at birth. My wife is in recovery from Breast Cancer. If we have to pay part of the expenses, then we will. Nothing is free. If someone else gets something for free, it is because someone else is paying for it. Let everyone share in the costs at some level. I am a smoker and i should and will pay a higher price. Smoking is my issue not anyone elses. Public be responsible for your own health. Let’s help the few that cannot pay. Take a hard look at what the rest of the world has. We are exceptionally lucky to have what we have.


I am very concerned about the ACA and cancer treatment. I know I am not the only one. I am a stage 2 breast cancer but participating in chemo largely to take care of the “floater” cancer cells in my body.

I am concerned because my small employer (under 50) does pay us a smaller wage than the national average but we have the cadillac plan. my family gets great benefits. I get some perks like working from home when the child is sick. Needless to say, our employer wants to keep our insurance the same and is working hard at it.

I can’t see how this is going to be affordable to anyone who works and has a family to take care. Then when cancer when diagnosed, how can these folks pay $1,200 per month in addition to the monthly rise in premiums to all the other out of pocket expenses that come with cancer and believe me there are out of pocket expenses medically related.

We cancer patients need to get organized.

I read a blog on another website from someone in France. The blog concerned that Americans are lazy and need to protest– not in the weak amount of people showing up for the protest but millions showing up.

I also heard through media that Congress is working hard to get them exempt from the ACA.

uvaldo cantu

I am not a supporter of Obamacare. However, no one should be left out of care of ant kind weather cancer or diabetis etc. and the health system should be”fixed immediately.