Medicare and Cancer Care Reform: Closing the Gaps in Access and Affordability

Postdoctoral fellow Youngmin Kwon discusses how Medicare eligibility reduces financial barriers for cancer survivors, and why disparities in access and affordability still persist.

Please introduce yourself by stating your name, title, and any relevant experience you’d like to share.

Youngmin Kwon: My name is Youngmin Kwon. I am a postdoctoral fellow in health policy at the Vanderbilt University School of Medicine. My research examines access and affordability care for patients with cancer and cancer survivors, with a focus on the role of Medicaid and Medicare programs in alleviating financial barriers to care that patients with cancer face.

Your study shows a sharp drop in delayed or skipped care at age 65 with Medicare eligibility. From your perspective, what aspects of Medicare most directly enable older cancer survivors to access needed care, and where do you see the biggest remaining gaps?

Kwon: To me, the biggest appeal of Medicare is that it is a universal program that issues health insurance coverage for those who are 65 years old or older, and those with disabilities. The fact that we see a sharp drop in cost barriers to care among cancer survivors suggests considerable gaps in insurance and access to care prior to attaining eligibility for Medicare.

In our health care system, the primary source of insurance coverage for younger adults is employers, which fundamentally creates many gaps in coverage. In the context of cancer survivorship, a major concern is that survivor’s ability to work may be impacted by cancer, which may result in lapses in employer-sponsored coverage. In such cases, unless you qualify for Medicaid or can afford private insurance in the Affordable Care Act Marketplace, there are likely no other sources of coverage and thus many may remain uninsured. Even among the insured, there are concerns about under-insurance. For example, there have been an increasing rate of enrollment in high-deductible health plans, which may impose substantial out-of-pocket cost burden.

In comparison, the story is much simpler on the Medicare side. It's a program you’re entitled to receive, and even though it is not a perfect coverage, the continuity of the benefit and fewer restrictions in care (especially if you’re in Traditional Medicare) may contribute to improvements in access and affordability.

Even with near-universal Medicare coverage, nearly 30% of older cancer survivors still face affordability or access challenges. What factors within the broader cancer care system do you see as driving these persistent financial burdens, and how might policy better address them?

Kwon: On the Medicare side, the foremost challenge is how to best ensure that beneficiaries can meet the confluence of health care needs that arise from cancer diagnosis.

For those who are recently diagnosed with cancer, they may wrestle with cost of cancer-directed treatments, which has been increasing across the board. Newer innovations in treatments (for example, targeted or immunotherapies) offer promises in terms of improving survival, but they impose catastrophic expenses. Treating cancer also entails many inpatient and outpatient visits, which can be costly and burdensome. Coordinating all these services in a financially sustainable manner can be difficult.

Long-term cancer survivors who are in remission also experience unique needs for care, though we have less data on survivorship needs. In general, long-term survivors tend to have more comorbidities (perhaps due to the side effects of treatment) which may generate higher care needs compared to the general Medicare population. Furthermore, survivors need to be monitored for cancer recurrence, which involves ongoing access to diagnostic and screening services.

Overall, there is a whole spectrum of care needs throughout the cancer care and survivorship spectrum. It is important to think about how Medicare can address the specific needs at each point of the care continuum.

Do you see differences in how Medicare reduces access barriers for different subgroups of older cancer survivors (eg, racial and ethnic minorities, rural vs urban populations, and low-income individuals)? If so, what targeted solutions might help ensure equity in access?

Kwon: We do find that the benefits of Medicare eligibility are more pronounced among the subgroups mentioned, particularly racial and ethnic minorities and those with lower levels of education. Those are the groups that likely have less access to insurance before they are age-eligible for Medicare. That reaffirms the value of Medicare as a near-universal program. It’s encouraging that attaining Medicare eligibility does reduce the disparities in coverage and access that exist among younger adults.

Among younger adults, major insurance expansions—such as Medicaid expansion and improving the ACA marketplace—have been pivotal in addressing gaps to coverage. Further building upon these expansions would be greatly important to ensuring equity. Moreover, there have been proposal to improve access to Medicare, such as lowering the age-eligibility for Medicare, which could also increase access to those without options for coverage.

Given your findings, what reforms to Medicare—or complementary policies—do you think would be most impactful in further reducing cost-related barriers for cancer survivors?

Kwon: Even within Medicare, there is a lot of variability in access and affordability, which reflect differences in how beneficiaries receive Medicare benefits.

In Traditional Medicare, beneficiaries face few or no restrictions in care, but are responsible for high cost-sharing without no protections for catastrophic costs. For example, the 20% coinsurance in Medicare Part B (covering outpatient and office-based services) could mean that cancer patients receiving expensive infusions are responsible for enormous out-of-pocket costs.

To reduce or eliminate such costs, many beneficiaries obtain supplemental coverage, such as Medigap private supplemental insurance. However, purchasing supplemental coverage means paying for additional monthly premiums that may not be affordable for everyone.

The other type of Medicare coverage is Medicare Advantage, a managed care alternative to Traditional Medicare. While out-of-pocket costs may lower in Medicare Advantage (mostly due to the fact that Medicare Advantage includes an out-of-pocket limit and cost-sharing may be lower), there are restrictions in access to care. Among cancer survivors, there have been frustrations with limited provider networks and prior authorization process.

Overall, there are important trade-offs in access and affordability between these two coverage options. I don’t think we have robust evidence yet to conclude which program provides better coverage for cancer survivors. However, there may be more “low-hanging fruit” reforms to address the salient affordability issues. For example, perhaps we could establish an out-of-pocket maximum in Traditional Medicare or expand the Medicare subsidies for low-income Medicare beneficiaries that essentially provide supplemental coverage. Furthermore, the quality of care in Medicare Advantage needs to be monitored to ensure that patients can access high-quality oncologic care.

Based on your findings, how do you see access and affordability for older cancer survivors evolving over the next 10 to 15 years?

Kwon: We have made a lot of strides on this front. After decades of research, many stakeholders in the system are now keenly aware of the financial toxicity of cancer care. Researchers have been doing a stellar job of documenting the extent to which patients experience financial toxicity and studying interventions to alleviate financial toxicity.

Moving forward, we're still going to be wrestling with how to pay for costly cancer care. With newer medical innovation coming along, cancers can be treated more effectively, but there will always be concerns about access and affordability.

One example of this is gene and cell therapy for rare cancers. It is remarkable in terms their clinical efficacy, but the cost is so astronomical there are concerns about potential disparities in access. Obviously, insurance is a key mechanism to facilitate access to treatments, but how to design coverage in a way that is affordable and financially sustainable for the Medicare program is a tough question.

On the other hand, we need more research on access to cancer care in Medicare Advantage, which now covers more than half of Medicare beneficiaries. We lack robust evidence regarding access to oncologic care that may be impacted by utilization management tools such as provider networks and prior authorizations. Further research in these domains will be valuable to policymakers and other stakeholders who are constantly discussing for the ways to reform the Medicare program.