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Despite declines in cancer death rates since the early 1990s, cancer remains the second leading cause of death in the United States.1 In 2020, an estimated 1.8 million people received a new cancer diagnosis and 600 000 died from cancer.2 Cancer care is also costly. Spending on cancer-related care was estimated at $183 billion in 2015 and is projected to increase to approximately $246 billion by 2030.3 Even though insurers cover a substantial portion of this spending, many patients with cancer experience high out-of-pocket spending. This has been recognized as an additional “adverse effect” of undergoing cancer care, termed financial toxicity. Prolonged treatment courses mean that many patients have very high levels of health care spending year after year, rather than in a single year following initial diagnosis. Given the high costs associated with cancer treatment, access to health insurance and limits on out-of-pocket spending are critical for patients. President Biden’s proposals for health care to increase enrollment in health insurance for uninsured individuals and improve coverage and reduce costs among the insured would thus be especially valuable for patients with cancer.4
In 2019, approximately 14% of adults aged 18 through 64 were uninsured,5 primarily due to not having affordable coverage available (74%) and not being eligible for health insurance (25%).5 Lack of insurance contributes to delayed cancer detection, later stage at diagnosis, and worse health outcomes for individuals with cancer. To improve uptake of health insurance, the Biden plan seeks to increase the generosity of and expand eligibility for the exchange plans in the Affordable Care Act (ACA).4 Today, persons with incomes higher than 400% of the federal poverty level (FPL) receive no subsidies to lower their costs for obtaining coverage. The Biden plan would extend eligibility for tax credits beyond 400% of the FPL and lower the limit on the cost of coverage from 9.86% to 8.5% of income, regardless of income. This could improve affordability of insurance premiums for individuals who previously received no premium subsidies. These plans will also include more generous benefits than the standard plans offered under the exchange today, with lower out-of-pocket spending for beneficiaries when they seek care.
The Biden plan also aims to fill a key gap in coverage for adults in states that did not expand Medicaid. In nonexpansion states, individuals with incomes lower than 100% of the FPL are not currently eligible for subsidies on the ACA’s exchange plans.6 Under the Biden proposal, these individuals would be automatically enrolled into $0 premium coverage if they live in a state that has not expanded Medicaid. This option would also be made available to states that had previously expanded Medicaid. In addition, the Biden plan would extend coverage to individuals previously ineligible for enrollment in public plans, including legally present immigrants, and also would allow undocumented immigrants to purchase unsubsidized exchange plan coverage. These efforts are likely to address 2 of the leading barriers to insurance enrollment today.
A second challenge is to ensure that insurance coverage is adequate for meeting the needs of patients with cancer, as well as others who have high health care spending. Affordability can vary by the type of services needed, even with coverage by the same insurance plan. Because of provisions within the ACA, commercially insured individuals have annual out-of-pocket limits for in-network health care spending that includes both medical and pharmacy services. Even though this may still represent a significant expense ($8550/individual; $17 100/family in 2021), for patients who require ongoing cancer treatment, it does provide significant financial protection.
However, Medicare beneficiaries, the population most affected by cancer, lack these comprehensive limits on out-of-pocket spending. First, beneficiaries enrolled in traditional Medicare without supplemental coverage must pay 20% of Medicare’s negotiated amount for all medical services received, with no out-of-pocket limit. This includes any outpatient care, such as radiation therapy and infused therapies under Medicare Part B. Even among Medicare beneficiaries with supplemental insurance or an out-of-pocket limit on their Medicare Advantage plans, there is no limit on outpatient prescription drug spending under Medicare Part D. For patients with cancer, this is a significant concern as many new anticancer drugs are covered under Medicare Part D and the average price for these products was more than $14 000 per month of treatment in 2018.7 These drugs are often used for years, with expected out-of-pocket spending for most orally administered anticancer drugs covered by Medicare Part D exceeding $10 000 per year for a single drug.7
The proposed Biden plans address some of these affordability concerns by proposing to reduce prices for new anticancer drugs for Medicare and other payers, limit price increases for existing drugs, and cap beneficiary out-of-pocket spending in Medicare Part D. Specifically, drug price negotiation would include capping Medicare and other public and private payer spending to levels similar to other countries with similar economies. In addition, spending would be prohibited from increasing faster than inflation in Medicare and the public option, and launch prices for new drugs would be scrutinized and set based on recommendations made by an independent review board. Given their high prices, it is likely that most anticancer therapies would undergo independent review. The goal of this review would be to determine the value-based price for such therapies, requiring sufficient clinical gains for the dollars spent. These efforts to lower spending on medications could reduce spending for health plans and patients. Payers could use those savings to increase the generosity of health plan coverage for anticancer drugs to ensure better affordability for patients needing treatment.
For all of these plans, what might the Biden administration actually be able to achieve? Broadening access to health insurance will require congressional action for some of the more substantial reforms, although much can be done in budget reconciliation or through executive action.8 While the coronavirus disease 2019 (COVID-19) pandemic may serve as a motivator for improving access to health insurance, it may be a barrier to implementing broad reforms to drug pricing. Drug pricing reform is particularly sensitive today as the world awaits widespread distribution of COVID-19 vaccines. Members of Congress may be reluctant to rein in drug company profits when the threat of doing so is met with mounting concerns regarding harm to future innovation. This is also a significant concern for patients with cancer, whose lives depend on future innovation. Yet several of these goals related to addressing drug spending have been outlined in the previous Congress and share bipartisan support. This includes reforms to the Medicare Part D program that encourage lower-priced drug use and that cap beneficiary out-of-pocket spending, along with limits to price increases on existing drugs. Even though these measures do not address the looming problem of ever-increasing launch prices for new drugs, they are meaningful improvements over the status quo.
More advanced policy changes, like establishing value-based prices for new drugs, are likely to be difficult. However, value-based prices could be advantageous for patients with cancer because they would require clear evidence of benefit from new therapies. Much of the policy focus on improving access to prescription drugs and lowering costs for patients is conditional on the assumption that the drugs physicians prescribe are worth the money, although that is not always the case. The evidence base supporting more recent approvals for anticancer therapies has eroded,9 making it difficult to disentangle whether a new treatment provides any additional value over an older treatment. Even when evidence is lacking, marketing and promotion, along with payment systems that provide incentives to use higher-priced over lower-priced drugs, can bolster adoption of new products over existing therapies. This lack of comparative data are problematic for individuals with cancer and their families who deserve to understand the benefits and costs of pursuing a new treatment vs the existing standard of care.
There are reasons to be optimistic about President Biden’s proposals to improve access to and affordability of cancer care. Cancer care is a priority for Biden. His family has experienced the pain of losing someone too soon due to cancer, and he has invested time and resources in leading the Cancer Moonshot program and the Biden Cancer Initiative. His commitment to science may result in increased funding for new discoveries that improve outcomes for those with cancer. His commitment to ensuring better access to health insurance and lower costs for patients (especially for drugs) could motivate needed policy changes. This would be a great start for many individuals with cancer who have concerns that they will not be able to afford treatment or for whom coverage has been either unaffordable or unavailable in recent years.
Corresponding Author: Stacie B. Dusetzina, PhD, Department of Health Policy, Vanderbilt University School of Medicine, 2525 W End Ave, Ste 1203, Nashville, TN 37203 (firstname.lastname@example.org).
Conflict of Interest Disclosures: Dr Dusetzina reported receiving research funding from the Commonwealth Fund, the Leukemia & Lymphoma Society, Arnold Ventures, and the Robert Wood Johnson Foundation; honoraria from West Health and the Institute for Clinical and Economic Review; and having served as a consultant for the National Academy for State Health Policy on an unrelated project.
Dusetzina SB. Cancer Care Under the Biden Administration. JAMA. 2021;325(6):527–528. doi:10.1001/jama.2020.25424
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