The domino effect of missed cancer screenings

From delayed check-ups to postponed elective procedures, missed or deferred care during the pandemic will continue to strain the healthcare delivery system for the foreseeable future. The graphic above shows the impact on cancer care: both cancer screenings and new diagnoses are still down from pre-COVID levels.

Screenings for breast, colon, and cervical cancers were significantly lower in 2020, and patients missed about 10M total screenings in the pandemic’s first year alone. While cancer screenings rebounded somewhat in 2021, they were still below pre-pandemic levels. Unsurprisingly, the downstream impact has been a similar decline in new cancer diagnoses.

The negative effects of care delays have become increasingly obvious: there has been an increase in the number of patients presenting with later-stage cancersThere was a six percent increase in Stage 4 breast cancer diagnoses, and a 16 percent increase in Stage 2 and 3 cancer diagnoses in 2021, compared to 2019.

With no reason to believe that either cancer incidence or acuity has actually changed, oncology providers must increase their screening capacity and double down on reaching out to patients who are overdue for screenings. But as providers continue to work through the backlog of missed exams, they must prepare to treat more complex, higher-acuity cancer patients than ever before.

Health Agency Preparing for Lapse in Extra ACA Subsidies

https://news.bloomberglaw.com/pharma-and-life-sciences/health-agency-preparing-for-lapse-in-extra-obamacare-subsidies?mkt_tok=ODUwLVRBQS01MTEAAAGDWuGQisFiXP1YU7ldhH-D-v-Qezz0Y7Ol85lQV_EWybFJCX5nhwm1xijPeqwqKvJ4KM_KHbGLJ6Tq5fpqr7aHTFGKPLChP3FMmQbI5dZoOR8W

  • Obamacare enrollment at a record-high 14.5 million
  • Congress may not fund premium subsidies in 2023

The Affordable Care Act marks its 12th anniversary Wednesday, and despite a record 14.5 million enrollees, the Biden administration is preparing for the possibility that millions could lose coverage next year.

The $1.9 trillion pandemic stimulus package (Public Law 117-2), signed March 2021, reduced Obamacare premiums to no more than 8.5% of income for eligible households and expanded premium subsidies to households earning more than 400% of the federal poverty level. The rescue plan also provided additional subsidies to help with out-of-pocket costs for low-income people. As a result, 2.8 million more consumers are receiving tax credits in 2022 compared to 2021.

But without congressional action, the subsidies—and the marketplace enrollment spikes they ushered in—could be lost in 2023. new HHS report released Wednesday, shows an estimated 3.4 million Americans would lose marketplace coverage and become uninsured if the premium tax credits aren’t extended beyond 2022.

In a briefing with reporters Tuesday, Chiquita Brooks-LaSure, administrator for the Centers for Medicare & Medicaid Services, said her agency is “confident that Congress will really understand how important the subsidies were” to enrolling more people this year. The CMS would “pivot quickly,” however, to implement new policies and outreach plans if the subsidies aren’t extended as open enrollment for 2023 begins in November.

“That said, today and tomorrow we are celebrating the Affordable Care Act,” Brooks-LaSure added. “As part of that process, we’ve been reminding ourselves that sometimes it takes some time to pass legislation. And just like the Affordable Care Act took time, we’re confident that Congress is going to address these critical needs for the American people.”

After years of legal and political brawls that turned the landmark legislation into a political football, Obamacare “is at its strongest point ever,” Brooks-LaSure said. The 14.5 million total enrollees—those who extended coverage and those who signed up for the first time—is a 21% increase from last year. The number of new consumers during the 2022 open enrollment period increased by 20% to 3.1 million from 2.5 million in 2021.

This week, the Department of Health and Human Services will highlight the impact of the ACA and the Biden administration’s efforts to strengthen the law. The CMS recently announced a new special enrollment period opportunity for people with household incomes under 150% of the federal poverty level who are eligible for premium tax credits. The new special enrollment period will make it easier for low-income people to enroll in coverage throughout the year.

Troubled times could be around the corner, however, as millions of people with Medicaid coverage could become uninsured after the public health emergency ends. Under the Families First Coronavirus Response Act (Public Law 116-127), signed March 2020, states must maintain existing Medicaid enrollment until the end of the month that the public health emergency is lifted. Once the continuous enrollment mandate ends, states will resume Medicaid redeterminations and disenrollments for people who no longer meet the program’s requirements.

Dan Tsai, deputy administrator and director of the Center for Medicaid and CHIP Services at CMS, said the agency is working with states to make sure people who lose Medicaid coverage can be transferred into low- and no-cost Obamacare coverage.

“A substantial portion of individuals who will no longer be eligible for Medicaid will be eligible for other forms of coverage,” including marketplace coverage, Tsai told reporters Tuesday.

In a statement, President Joe Biden acknowledged the law’s great impact. “This law is the reason we have protections for pre-existing conditions in America. It is why women can no longer be charged more simply because they are women. It reduced prescription drug costs for nearly 12 million seniors. It allows millions of Americans to get free preventive screenings, so they can catch cancer or heart disease early—saving countless lives. And it is the reason why parents can keep children on their insurance plans until they turn 26.”

The Affordable Care Act: Twelve Years and Nine Lives Later

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A new spring brings another anniversary of the Affordable Care Act. Twelve (sometimes tumultuous) years later, this remarkably resilient law is on firmer ground than ever before.

So what are some highlights?

The uninsured rate remained stable even in the face of a global pandemic. Congress leveraged parts of the ACA to quickly cover COVID-19 tests and vaccines without cost sharing.

The American Rescue Plan Act supercharged marketplace subsidies, leading to record-high marketplace enrollment.

And there are currently no existential legal threats to the law working their way through federal courts.

In some ways, this rosy report feels unremarkable. Why expect otherwise with the law now in place for more than a decade and baked into every part of the health care system?

But this outcome was far from inevitable.

Just five years ago, Congress tried to repeal as much of the law as possible. When those broader efforts failed, Congress eliminated the much-maligned individual mandate penalty. We appeared to have reached a stalemate: Democrats could not improve the law while Republicans could not repeal it.

Could this be the moment we moved on from ACA politics?!

Enter the courts. In early 2018, Republican attorneys general sued to invalidate the mandate and, with it, the rest of the law. That lawsuit—California v. Texas—was ultimately heard by a new Supreme Court one week after the 2020 election, and the ACA was upheld just last summer.

This marked the third time that the Supreme Court largely rebuffed what could have been a crippling legal challenge to the law. It feels like ancient history now, but it is worth remembering that we were still playing “will they or won’t they?” with the Supreme Court and ACA only one year ago.

In the meantime, the Trump administration tried to undermine access to coverage under the law—except when it didn’t. I won’t list all the relevant Trump-era policies, but they had an impact: the uninsured rate rose, and marketplace enrollment declined until the 2021 plan year.

Ironically, one policy meant to destabilize the market had the opposite effect: so-called “silver loading” led to more generous marketplace subsidies and likely helped stave off even greater coverage losses.

This is the recent history that is top of mind as I reflect on the year ahead—and the work left to do to achieve universal coverage. Here are just some of the major issues facing policymakers:

     • The clock is ticking to extend the American Rescue Plan Act subsidies. If Congress fails to do so, millions will face premium hikes next year and marketplace enrollment will likely drop.

     • More than 2 million low-income people remain stuck in the Medicaid coverage gap in the 12 states that have not yet expanded their Medicaid program.

     • Up to 15 million people, including nearly 6 million children, could lose Medicaid coverage at the end of the COVID-19 public health emergency.

     • There is increasingly an affordability and underinsurance crisis, including for those with job-based coverage: an estimated 87 million people were underinsured in 2018.

Congress and the White House are working to address these challenges, but much uncertainty remains.
“It feels like ancient history now, but it is worth remembering that we were still playing ‘will they or won’t they?’ with the Supreme Court and Affordable Care Act only one year ago.” – Katie Keith

Looking beyond Congress, 2022 will be an important year for regulatory changes. The Biden administration has proposed, but has not yet finalized, major marketplace changes. Other already-identified priorities include fixing the family glitch, limiting short-term limited duration insurance, and enhancing nondiscrimination protections. We could see movement on at least some of these rules soon.

While the Biden administration may be waiting out Congress before initiating some rulemaking, time is of the essence. New rules take many months to adopt and then take effect—followed by more time to deal with the legal challenges that typically follow.

Follow along as I dive deep on these issues and more in a new Health Affairs’ Health Reform newsletter.

We’ll highlight the latest health policy developments—from legislation to litigation—and explain what these changes mean for patients, payers, providers, and other key health care stakeholders.
It’s Your Birthday, Affordable Care Act!
In March 2020, Health Affairs published a theme issue to celebrate the tenth anniversary of the Affordable Care Act. The issue contains many illuminating research articles on the landmark legislation, from its impact on “the cost curve” to Medicaid expansion.

Above is a datagraphic from the issue showing how the ACA affected insurance coverage.

Out-of-pocket limits aren’t silver bullets

Part of the reason why medical debt is so high is because many Americans don’t have enough savings to pay their deductibles and other out-of-pocket costs, according to a second KFF analysis.

Driving the news: Health insurance plans’ out-of-pocket limits prevent enrollees from paying limitless sums of money for medical care. But that doesn’t mean they protect people from having to pay several thousands of dollars — which not everyone has lying around.

  • Deductibles alone, which people must pay before coverage for most services kicks in, are frequently thousands of dollars and can exceed the amount of liquid assets a household has.

By the numbers: Over 40% of multi-person households can’t cover a mid-range employer family plan deductible of $4,000, and 61% don’t have enough to cover a high-range deductible.

  • The ability to pay out-of-pocket costs varies significantly by income.

America’s giant medical debt

Americans owe at least $195 billion of medical debt, despite 90% of the population having some kind of health coverage, according to new research from the Peterson Center on Healthcare and the Kaiser Family Foundation.

Why it matters: People are spending down their savings and skimping on food, clothing and household items to pay their medical bills, Adriel writes.

About 16 million people, or 6% of U.S. adults, owe more than $1,000 in medical bills, and 3 million people owe more than $10,000.

  • The financial burden falls disproportionately on people with disabilities, those in generally poor health, Black Americans and people living in the South or in non-Medicaid expansion states, per the research.

Go deeper: 16% of privately-insured adults say they would need to take on credit card debt to meet an unexpected $400 medical expense, while 7% would borrow money from friends or family, per the research, which focused on adults who reported having more than $250 in unpaid bills as of December 2019. 

It’s not yet clear how much the pandemic and the recession factor into the picture, in part because many people delayed or went without care. There also was a small shift from employer-based coverage to Medicaid, which has little or no cost-sharing.

  • While the new federal ban on surprise billing limits exposure to some unexpected expenses, it only covers a fraction of the large medical bills many Americans face, the researchers say.

Surgery delays: A pandemic effect patients, care teams dread

Surgery delays: A pandemic effect patients, care teams dread

Omicron and staffing constraints pushed hospitals and health systems to once again suspend nonurgent, elective procedures — a move that hurts patients and their care teams.

Physicians told The Washington Post that notifying patients of their surgeries being postponed is one of the most difficult things they do during the pandemic, and the idea of prolonging patients’ suffering is anguishing. In interviews, a patient rated the pain he felt from a ruptured cervical disk — for which his surgery has been indefinitely postponed at Mercy Health-St. Rita’s Medical Center in Lima, Ohio — as a 12 out of 10. 

In addition to extended pain, pushed back surgeries leave more time for disease advancement. Certain cancers can advance to later stages in four to eight weeks, for instance. Even procedures considered low acuity, such as joint replacements or bariatric cases, will have material implications from delays through reduced activity, mobility and quality of life for patients. Delays in surgery have also been shown to result in higher rates of surgical site infections.

“I’d say it’s a bona fide mess right now,” Kenneth Kaufman, chair and founding partner of Kaufman Hall, told The Washington Post. “We seem to be back to square one. Omicron has significantly compounded staffing shortages in a very profound way.”

Hospitals hit pause on surgeries over the last several weeks as growing COVID-19 inpatient volumes were compounded by omicron sidelining healthcare professionals infected with the virus. Vaccinated healthcare professionals experienced mild breakthrough cases that temporarily took them out of the workforce. 

Cleveland Clinic has extended its postponement of elective surgeries four times over the past month as thousands of employees were sidelined from COVID-19 infection. Hospitals in New YorkChicagoSt. LouisWashington and Virginia are among those that have either moved back surgeries or complied with government officials’ requests to do so in January.   

Healthcare professionals have taken issue with the industry term “elective,” which does not describe the acuity of the medical condition or necessity of the procedure. Rather, the use of “elective” distinguishes these surgeries that are scheduled in advance from emergency surgeries, such as trauma cases. 

University of Utah Hospital in Salt Lake City postponed about 20 percent of its surgeries when at least 500 clinical and nonclinical employees were out sick or isolating from COVID-19 at the start of the month. 

“Around Christmastime and the week after Christmas, we didn’t have to reschedule any operations for a period of three weeks, until January 1. Then the wheels came off,” Robert E. Glasgow, MD, interim chair of the hospital’s surgery department, told The Washington Post

On Jan. 14, the physicians at the hospital learned they could accommodate six additional surgery cases Jan. 18, leaving them in a mad dash to identify priority patients and determine who could present for surgery with less than four days’ notice. 

“How can we find six cases that are most in need and are most able to come?” said Dr. Glasgow said.

Omicron exacerbates existing staffing shortages

https://mailchi.mp/0b6c9295412a/the-weekly-gist-january-7-2022?e=d1e747d2d8

  1. The incredibly contagious new coronavirus variant is sidelining healthcare workers with breakthrough infections and quarantines, as patients flood into hospitals across the country. While hospitals are reporting that most infected patients are less sick, the sheer number of patients is pushing an already stressed system into crisis. 

The Gist: Given mounting evidence that Omicron is both causing less severe disease and evading vaccines, health systems will need to balance employee COVID testing and quarantine protocols against the constraints caused by mounting numbers of otherwise asymptomatic care workers out sick. As COVID becomes endemic, health systems must find a way to normalize operations even as they manage employee infections. It won’t be sustainable to continually revert to canceling non-emergent procedures (many of which carry clinical consequences to patients if they are delayed) and shifting to crisis standards of care. 

Consumer confidence unshaken by Omicron—at least so far

https://mailchi.mp/0b6c9295412a/the-weekly-gist-january-7-2022?e=d1e747d2d8

While Omicron’s rapid spread is causing COVID hospitalizations to surge once again, the impact on consumer confidence may be different this time around. Drawing on the most recent data from analytics firm Strata Decision Technology, the graphic above shows how hospital volumes have fluctuated throughout the pandemic. Hospital volumes mostly returned to pre-COVID levels early last summer, until the Delta surge caused patients to begin avoiding care across all settings once again. 

It remains to be seen if the forty percent of consumers who said they were less likely to seek non-emergency care during the Delta surge feel similarly about the Omicron spike. So far, consumer sentiment seems to be holding steady at last summer’s levels, though we’re still a few weeks away from Omicron’s expected peak. 

As the pandemic enters its third year, it’s also likely that consumers who have been delaying care will simply be unwilling or unable to hold off any longer. But even if Omicron doesn’t dissuade consumers from seeking non-COVID care, health systems will be hard pressed to accommodate both COVID and non-COVID care amid worrisome staffing shortages. 

Many Americans Remain Uninsured Following Layoffs

https://www.managedhealthcareexecutive.com/view/many-americans-remain-uninsured-following-layoffs

See if Coverage Loss Qualifies for Special Enrollment Period Today |  HealthCare.gov

Job losses from the COVID-19 pandemic are the highest since the Great Depression. A year and a half later, most Americans who lost their health insurance along with their job remain uninsured.

Most Americans who lost their jobs and health insurance more than a year ago remain uninsured.

Over 1,200 Americans who are still unemployed due to COVID-19 were surveyed by AffordableHealthInsurance.com. At least four out of five in all participants don’t have insurance coverage.

To be exact, 56% of Americans who remain unemployed since being laid off due to the COVID-19 pandemic lost their health insurance along with their job. In addition, 23% of workers did not have employer-provided health insurance prior to losing their jobs.

Even before the pandemic, small businesses struggled to absorb the cost of providing health insurance to their employees, said health insurance advisor and nursing consultant Tammy Burns in the Affordable Health Insurance study.

“Companies have cut costs by going with high-deductible plans and sharing less of the cost towards the insurance,” Burns said. “This makes it cheaper for employees to get their own health insurance through the Affordable Care Act (ACA) marketplace. At larger companies, health care costs are growing faster than worker wages, so a large amount of an employee’s check goes to insurance. Therefore, many workers opt out because they can’t afford it.”

Majority of Those Who Lost Health Insurance Still Lack Coverage

Of the 56% of unemployed Americans who lost their health insurance along with their job, 81% are still uninsured.

This lack of coverage is impacting certain groups more than others. There are also several contributing factors to why the number of unemployed Americans without health insurance remains high.

These factors are:

  • Men more likely to remain uninsured than women

When broken down by gender, men are more likely than women to have lost their health insurance when they lost their jobs at 66% and 44%, respectively. However, women are twice as likely as men to have not had health insurance in the first place at 31% and 16%, respectively.

Currently, men are slightly more likely to still be uninsured. Eighty-four percent of male survey respondents do not currently have health insurance, compared to 75% of women.

  • Majority of unemployed Millennials, Gen Xers still uninsured

Our survey also found that certain age groups are more likely than others to still be uninsured after a pandemic-related job loss.

Eighty-six percent of individuals ages 35 to 44, and 84% of both 25 to 34 year-olds and 45 to 54 year-olds remain without health insurance after being laid off. Comparatively, 67% of unemployed individuals 18 to 24, and 58% of those older than 55 are still uninsured.

Americans ages 25 to 44 are also the age group most likely to have lost their health insurance when they were let go from their jobs (66%).

  • Inability to Afford Private Insurance The Top Reason to Remain Uninsured

The high cost of individual insurance is the number one reason Americans still unemployed from the pandemic remain uninsured.

Sixty-seven percent of those uninsured can’t afford private health insurance. Eleven percent of people who still lack health insurance say they did not qualify for government-funded health insurance, despite the fact that a number of states expanded access to Medicaid during the pandemic.

A lack of understanding about how the ACA marketplace works may also play a role in why uninsured Americans are not pursuing all possible avenues to get health insurance.

“People are scared of the ACA because it involves a lot of personal information, like taxes,” Burns said. “I have found that many people are afraid it is ‘the government being in my business.’ There is a lack of knowledge about how helpful and affordable the ACA is now. There needs to be better education about this program.”

  • One in five uninsured Americans choose not to have health insurance

The survey also found 20% of unemployed Americans who are uninsured choose to forgo health insurance altogether.

This is particularly true for men, 22% of whom are choosing not to have health insurance, compared to 15% of women.

Younger adults are also more likely than older Americans to opt out of health insurance if they are unemployed. Twenty-five percent of 25 to 34 year-olds, and 20% of 25 to 34 year-olds choose not to have health insurance.

  • Medication, Routine Checkups Skipped Due to Lack of Insurance

A lack of insurance has serious short- and long-term implications for individuals’ health and well-being. The biggest impact: 58% of uninsured individuals are no longer getting routine care, which could hinder their ability to identify more serious underlying issues.

Other impacts include no longer taking doctor-prescribed medication (56%); delaying planned medical procedures (46%); not seeking treatment for chronic issues (44%), and no longer receiving mental health treatment (41%).

  • Three-quarters of older Americans not getting regular check-ups

Our survey also found that those at greater risk for medical issues, based on age, are the most likely to be skipping their routine check-ups. Three-fourths of uninsured individuals over the age of 55 (76%) say they are not going for regular doctor visits because of their lack of insurance, the highest percentage of any age group.

Meanwhile, 64% of individuals 35 to 44 are not taking doctor-prescribed medication, which can have both short- and long-term negative effects.

  • Majority of Uninsured Americans “Very likely” to be Financially Devastated by Medical Emergency

Given that so many individuals are already hard-pressed to afford health insurance, it’s not surprising that many of them will also be in a dangerous place financially if there is a medical emergency.

Fifty-nine percent of uninsured people are “very likely” to be financially devastated by a medical emergency, while another quarter are “somewhat likely” to face financial ruin in the event of a medical emergency.