Oncologists Call for a Single-Payer Healthcare System in US

By Roxanne Nelson
Medscape Medical News, Jan. 28, 2014

The Patient Protection and Affordable Care Act (ACA), known as Obamacare, will not solve the healthcare crisis that cancer patients face. The only real solution, according to 2 oncologists, is a single-payer system of national healthcare insurance.

The crisis in healthcare is felt "more acutely" by cancer patients because the cost of cancer care, particularly new cancer drugs, has soared in recent years, say Ray Drasga, MD, a community-based oncologist in Crown Point, Indiana, and Lawrence Einhorn, MD, professor of medicine at Indiana University Hospital in Indianapolis.

In a report published in the January issue of the Journal of Oncology Practice, Drs. Drasga and Einhorn call on their fellow oncologists and American Society of Clinical Oncology (ASCO) to advocate for a single-payer national health insurance program.

The medical system needs to be oriented toward caregiving, not toward maximizing investors' profits, they say.

"We cannot in good conscience stand by and remain silent," they write. "Life is short, especially for some patients with cancer; they need help now."

"All of our patients deserve dignity," they conclude. "It is our moral and ethical obligation as physicians to advocate for universal access to healthcare. Oncologists, working in conjunction with ASCO, are well positioned to educate legislators about single-payer national health insurance. The time to start is now."

A single-payer system is one in which a public or quasipublic agency handles all healthcare financing. Depending on the particular system, healthcare delivery can remain in public or private hands. The system endorsed by the authors is basically "improved Medicare for all" and, in a number of ways, would resemble the current arrangement in Canada.

There would be universal, comprehensive coverage with free choice of providers, and all medical care would be covered, including provider visits, hospital care, prescription drugs, and rehabilitation, they explain. Copayments, deductibles, insurance premiums, and out-of-pocket expenses would be eliminated.

Cancer Care in Crisis Mode

Oncologists are finding it more difficult to care for patients because of the rising cost of treatment and the high prevalence of patients who are uninsured or underinsured, the authors note. Increasingly, oncologists are having to compromise on therapies so that patients can afford the treatment regimen.

"With the costs of cancer care skyrocketing out of control, most people with cancer are burdened not only physically, but also financially," said Dr. Drasga in a statement. "They delay or do not receive care due to their inability to pay."

Cancer patients feel the crisis in healthcare more acutely because of the high cost of drugs, tests, and procedures, he added. "For example, the cost of a new cancer drug has increased to a median price of $10,000 per month since 2010, and some drugs cost much more."

The cost of care has been a continuing challenge for patients and their physicians. As previously reported by Medscape Medical News, oncologists often do not discuss the cost of drug therapy with their patients. Many are also unaware of how much medication actually costs their patients.

In 2011, Richard Sullivan, MD, from King's Health Partners Integrated Cancer Centre in London, United Kingdom, and colleagues concluded that the cost of cancer care in high-income countries is becoming "unsustainable" ( Lancet Oncol. 2011;12:933-980). They noted that cancer care is rapidly becoming beyond the reach of all but the most affluent and the well-insured Americans, and that a drastic shift in cancer policy is needed to rein in current costs.

Dr. Drasga agrees. "The situation is worsening," he said. "We need a fundamental shift in our approach to funding healthcare in the United States."

In the United States, the healthcare system, including cancer care, has major problems. Millions are either uninsured or underinsured, the cost of medications is higher than in any other developed country, and the healthcare delivery system has transformed into an investor-owned business, Drs. Drasga and Einhorn point out.

Situation Will Worsen Under ACA

The ACA is not going to solve these issues, they note. It will not "remedy the problems of the uninsured, the underinsured, rising costs, [or] growing corporate control over caregiving."

The authors note that 48.6 million people were uninsured in 2011. Although the ACA is expected to lower that number, the Congressional Budget Office estimates that 31 million Americans will still be uninsured in 2023.

Similarly, the issue of underinsurance or insufficient coverage is likely to persist, if not worsen. "Insurance plans with limited networks of providers, along with high deductibles, copays, and out-of-pocket costs, are making underinsurance the new normal," they say. "The most affordable plans on the state health exchanges, the bronze and silver plans, leave 30% or 40% of healthcare costs, respectively, to be paid by policyholders."

In the ACA, the private insurance industry remains at the center of the health system. Drs. Drasga and Einhorn believe that the current trend toward high-deductible health plans, underinsurance, and cost shifting to patients will almost certainly get worse.

With the initiation of a single-payer plan, administrative overhead, which places an enormous economic burden on both physicians and facilities, would be dramatically reduced, the authors point out. Currently, 31% of every healthcare dollar in the United States is used for administrative overhead, which is double the rate in Canada. Although Canada has a separate insurance plan in each province, the situation in the United States is even more complex.

Each of the hundreds of insurance companies and thousands of different private plans has departments for marketing, eligibility determination, claims processing, and use review, not to mention profits to fund.

"As a result, private insurance overhead averages 14.0% of premiums, compared with the traditional overhead of Medicare of just 1.4%," they note.

"Overhead accounts for more than one quarter of all hospital spending in the United States because of the need to generate itemized per-patient bills for a plethora of plans and haggle over how much insurers will pay," they add.

The ACA has failed to address many of the problems in the American healthcare system, and years of solutions emanating from the private sector have failed. Therefore, there needs to be a "major paradigm shift" in the approach to funding healthcare, Dr. Drasga and Dr. Einhorn conclude.

The authors have disclosed no relevant financial relationships.

J Oncol Pract. 2014;10:7-11. Abstract