The Next Great Cure? A Cancer Doctor Explains Why He Supports the Affordable Care Act

What do Louis Pasteur, Jonas Salk, Sigmund Freud and Barack Obama have in common?  They all championed controversial medical revolutions and if not for their bravery in the face of conflict, billions would have died.

Sterilize instruments to kill invisible bugs? Inject disease particles to build immunity?  Look into our subconscious to explain everyday behavior?  Give basic healthcare to everyone?  Ludicrous.  That is why we named these advances after these men.

As an oncologist who has seen the fatal cost of our patchy, imbalanced and unfair healthcare system, I have to be at very least hopeful about ObamaCare; AKA the Affordable Care Act (ACA).  The list of benefits is so vast that whatever glitches happen along the way, I know that cancer patients will be helped:

-No pre-existing condition exclusion: So the 31-year-old programmer with Stage 1 breast cancer can change jobs without losing insurance.

-Healthcare coverage by parents until their child is 26: So families will not lose their homes paying for Hodgkin’ s disease in a 22-year-old.

-Guaranteed payment by insurers for patients entering experimental trials: So patients with any insurance can be involved in research, and everyone benefits from the latest advances.

-Free healthcare screening: So that my 58-year-old neighbor with a family history of colon cancer gets routine exams and life saving colonoscopies.

-Uniform healthcare insurance standards: So that the 45-year-old man with stomach lymphoma I saw last week, does not have to suffer and die because his employer brought a health policy, which excluded chemotherapy.

-All health insurance must cover at least one drug of each type: So patients do not have to choose which insurance by which drug they are taking, and prey the doctor does not change his mind.

-Emergency room visits do not require preauthorization and they cannot be charged as out-of-network: So that Monday morning my patient with lung cancer does not stumble into and collapse in the office after having a fever all weekend.

-Psychiatric parity: So that the 41-year-old Mom with advanced melanoma, two kids and a mortgage, whose husband just walked out on her, can get counseling and support.

-Insurers must cover hospitalizations without a lifetime cap on health costs: So that more than half a million families each year in America will not go bankrupt paying inpatient bills.

-Guaranteed physical therapy and rehabilitation: So that my patients who are cured of cancer have a real chance to get back to real lives.

-Prenatal care: So that the national disgrace that is a ridiculously high infant mortality rate will stop killing babies and I can hear children playing outside my window instead of tears.

-Health insurance for tens of millions of people: So that they can get care and, hopefully, their caregivers will be paid.

-Finally, and critically, health insurance and policies written not in lawyer-businessman language, but in clear English and every person is guaranteed the right to appeal any coverage decision.

I know that such a massive, complex undertaking, giving medical care to an entire nation, will not go without a hitch.  Rumor has it that Pasture kept burning his bands, Salk broke dozens of syringes and Freud, well Freud himself needed therapy.  Nevertheless, ObamaCare is a chance. A chance for us toward move toward a compressive, modern, world-class health system, instead of medical chaos, which may hurt as many as it helps.

My physician colleagues are concerned about the affect of the ACA on their relationship with patients. Doctors worry that information system enforced standards, increased volumes and decreased reimbursements may make it difficult to give personal care. These are important issues and protecting the quality of individual care is vital.  Still, I find that when I close the door to the exam room, that it is still just me and the patient and I can deal with the demands of a new system if it means that millions do not need to go without hope.

What is happening in Washington baffles me.  I cannot imagine any of us want to live in world where decisions already made, have no meaning.  For physician’s whose word and honor is the key to our bond to patients, that leaders would fail my patients so badly is horrifying.  My patients would be distraught if I told them I was going to order one treatment, but gave them another.   They would be desperate if I told them to come for a critical test, but locked the door.   Their worlds would collapse if the price for treatment were all their savings before we could even begin.  I would be betraying all that I know if I told patients they would live, but planned for them to die.

It is time to move on with this next step in a healthcare revolution, which started 150 years ago.  We can change, rebuild, add to or subtract, but for now and future generations we have to try.  Simply turning our backs on such an exciting future would be the same as spitting on our hands before operating, inviting polio to return, and treating psychiatric disease with pity.  We are smarter than that. We are better than that. We deserve more than that.  Let us move forward, not back.

James C. Salwitz, MD is a Medical Oncologist in private practice for 25 years, and a Clinical Professor at Robert Wood Johnson Medical School. He frequently lectures at the Medical School and in the community on topics related to cancer care, Hospice and Palliative Medicine. Dr. Salwitz blogs at Sunrise Rounds in order to help provide an understanding of cancer.

18 replies »

  1. re: What is happening in Washington baffles me.

    I feel there’s a need to restore the Fairness Doctrine allowing time for rebuttal on controversial issues that are broadcast on the public airways.

    Without this, persuasive talk show hosts can convince their captive audience that the ACA is an evil plan that must be stopped at all costs – by what-ever means necessary. Their representatives can only do the same if they hope to be re-elected.

  2. New York City, through its community health centers, takes care of 450,000 people who are uninsured (eg, waiters who earn too much to receive Medicaid). New Yorkers without insurance can through get healthcare including colonoscopies without paying for it.

    Other (developed) countries that have universal access for healthcare have high cigarette taxes (UK $7.50 per pack, France $6.00 per pack, Canada varies by province but in this range) which not only helps to pay for the healthcare but helps people to quit tobacco. More than half the contribution to help people to quit (and teens to never start smoking) is to increase the cost of tobacco. Yet, in the US, the ACA did not raise the tobacco tax to the level of UK or France but is instead $1.01 per pack. There are 18 billion packs smoked annually in the US so raising the taxes to the levels of UK and France would not only yield tens of billions of dollars for nationwide community health centers but also would help a significant proportion of the population of smokers to quit (and teens to never start).

    The American Cancer Society states that 1/3 of cancers is caused by smoking (and another 1/3 by obesity and lack of exercise). So, the best way to prevent cancer is to raise the cost of tobacco.

    What I really object to with ACA is that people who smoke, eat junk food and other lifestyle issues are supported by people who live a healthy lifestyle. Particularly unfair is the subsidy that young people (older than 26) must pay to those who have costly chronic disease from their lifestyles — the ACA forces the young to pay 1/3 the costs of these elderly even though their true costs are much lower than that.

  3. “I found an equivalent plan for about $950.”

    Single or family coverage?

  4. I have recently been a patient of the healthcare system in a way that I did not anticipate or want. I am also a cancer surgeon.

    There are two primary conflicts with the ACA – an ideological one and a financial one.

    Ideologically, the story of American individualism and the idea that we can dictate our destiny is a powerful one…that we can pull ourselves up with will and effort. It’s a great idea and an important one. It keeps us from falling into self pity, inertia and fatalism. But it doesn’t account for the growing disparity between the rich and poor in this country. And it doesn’t account for the significance of bad education and upbringing, bad genes, or just plain bad luck. And for this, certainly, in an advanced society, people should not be subject to bankruptcy from crushing medical bills or a constant fear about their health.

    Rob, this is why Obama accepted what he could get. That was his big lesson from the Clintons – take what you can get, then reshape it along the way.

    This is also the big reason why the Republicans are trying so hard to block it. They understand that once this program is fully launched, there will be no closing the gate. And to this end, Bob and Peter’s comments are spot on. It’s wonderful that so much more care will be covered. The existing system – and I say this as both a doctor and a patient – is complex at a level of indecipherability. When you’re sick, the last thing you should have to do is to figure out this kind of minutiae or be subject to small print that can be used to leave you with massive bills. But as much as current healthcare expenditures are unaffordable for the country and economy, I fear that the upcoming costs will be truly unmanageable.

    David Stockman (who served with President Reagan) wrote a piece recently discussing his alarm about the financing for the ACA, specifically focusing on the strong likelihood of more and more employers (in addition to Walgreens, IBM, and several recent others) sending their employees to the public marketplaces, thus increasing costs to an insurmountable number. This is the concern.

    That care that is important and the right thing to do, will simply cost too much for the government to pay. And given the current state of our ability to meet financial obligations, that has the potential to truly become an unfixable problem.

  5. But that doesn’t include what the company might already be contributing. Here’s a quote from a friend of mine, currently employed and nearing middle age with a family after checking out the exchanges:

    “My deduction plus my companies contribution is about $800 a month. I found an equivalent plan for about $950. It’s reassuring to see that I could leave my job to start my own bushiness and still be in the same range.”

    To Dr. Salwitz’s point, “So the 31-year-old programmer with Stage 1 breast cancer can change jobs without losing insurance.”

    And the healthy middle-ager with a family can start his own business and still afford insurance.

    This will add liquidity to the labor market and that’s good for everyone.

  6. “My point is all the reforms cited by Dr Salwitz are good — but can we afford them?”

    Thanks for the feedback Bob. As health insurance premiums continue to rise will congress afford higher subsidies or make the “A” in ACA meaningless – as it is now for your example family.

    Canada is having affordability issues as well and for a number of years has allowed private pay to wedge into the system. That may be OK for a middle class with rising wealth and able to pay, but I don’t see evidence here of any rising middle class to afford an already private pay system.

  7. Great post.

    “What is happening in Washington baffles me. I cannot imagine any of us want to live in world where decisions already made, have no meaning.”

    Here’s what I posted on my Facebook page:

    GOP Tea Party extremists from primary-immune right wing Obama-hater districts representing ~20% of Congress are now holding the nation hostage. This brazen display of Might Makes Right is the exact antithesis of the rule of law. They have soiled their offices. They are putting the nation in serious danger.

    Mr. Boehner, you are complicit in this nihilistic extortion by refusing to allow a House vote on the Continuing Resolution that would end this stand-off. It is a cowardly dereliction of your duty to the People as Speaker of the House.

    Mr. President, do NOT give in. If you do, there will be no end to this political thuggery. Your presidency will effectively be over. Democracy will effectively be over. We might as well appoint Ted Cruz Mullah in Chief and dissolve the legislative branch.

  8. With all due respect, if he were a true “revolutionary” and not another political vainglorious stuffed shirt, he would have championed universal health care. None of those giants of medicine would have been satisfied by a compromise.

  9. Peter, you always have good input. However my comment was directed at the issue of whether employers would actually drop group insurance in favor of the ACA exchanges.

    Still, where I think you are going is that health insurance is going to become even more expensive.

    Dr Salwitz makes excellent points about the good reforms in the ACA, including some I had not heard of. This law has many many quiet but significant provisions.

    Having some actuarial background, I can see at least 5 provisions that will raise health insurance premiums:

    – free screening including colonoscopies

    – no plan exclusions for chemotherapy

    – no lifetime limits

    – psychiatric treatment parity

    – coverage of physical therapy

    My understanding is that these mandates will apply to existing group insurance, not just the coverage to be sold in the exchanges.

    This means a 10-20 per cent increase in all group insurance premiums, maybe more, except for self funded plans (which will become more common).

    My point is all the reforms cited by Dr Salwitz are good — but can we afford them?

  10. Just to keep this discussion bedded in reality here’s a post by Bob Hertz in an earlier discussion.

    “But any transition has got to deal with the fact that most group insurance is community rated. Smokers and the ill and the middle aged are assessed the same premium as anyone else. The company gets a group rate.

    This is not true at all of the ACA. A 59 year old couple with no kids and a household income of $63,000 will face a family premium of $16,578 for a silver plan on most exchanges — and no subsidy whatsoever.”

    Tell me how this and other families will be able to afford this? Or the co-pays and deductibles that will come with a catastrophic illness.

    There will be many, many people/families that will be just outside the subsidy range and forced to still buy into the most expensive system in the world.

    Dr. Salwitz, the ACA does not solve the cost issue, THAT is the issue for U.S. healthcare.

  11. Great post…I strongly support the idea that the doctor has come up with that benefits the patient in a better way…This care act actually supports the cause of better treatment for the patients by reducing cost in treatment and posing much lesser risk for the patient.

  12. Great piece, and there are a few more big reasons, data and labor liquidity, which I wrote about when it passed in 2009. There’s an new health data science that is emerging (largely from data liquidity now that there’s a business model for leveraging and sharing data to uncover what treatments actually work to reduce costs in quality-based payment system along with much lower risk on the patient side to losing coverage, ) and liquidity in the labor market, people can move jobs more easily.