“How long do I have?”
The man was just diagnosed with lung cancer.
“That depends,” his doctor says. “What insurance do you have?”
New research suggests that conversations like these may be actually taking place across the country. Todd Pezzi and colleagues analyzed a national database for treatment outcomes for patients with limited stage non-small cell lung cancer, a diagnosis with high rates of response to treatment. The results, reported in JAMA Oncology last week were astounding: patients with Medicare, Medicaid, or no health insurance received different, and often worse, care than those patients with other types of health insurance. These patients were less likely to receive radiation therapy in addition to chemotherapy, part of the standard of care treatment. And they found that patients with Medicare or Medicaid were significantly less likely to survive their cancer than their counterparts with private insurance.
Clearly, the health insurance system is broken if different insurances determine what treatment a patient will get, even when there is a proven standard of care. Forcing patients and doctors to continue under what has been famously referred to as the patchwork quilt of our healthcare system is leaving people out in the cold.
These findings should alarm anyone who may be a patient one day – which, of course, is everyone. For me, a resident in internal medicine, the findings are also disquieting and discouraging. It’s frustrating to think that the best and most evidence-based treatments I spend many hours per week learning about may not even be available for some of my patients. I worry about being a part of a healthcare system where science and ethics take a backseat to billing groups.
To be sure, many will use this data to argue that the government shouldn’t be involved with health insurance at all. Although public insurance is often criticized as denying expensive or experimental drugs to patients, that’s not the issue here: radiation therapy in combination with chemotherapy is standard care for this cancer. Still, even if this hole is patched, it does nothing to address the underlying health insurance system with its persistent gaps and disparities in care.
After a tumultuous year of fighting over the Affordable Care Act, many progressives in Congress seem relieved to leave the fight over healthcare in 2017. The President and his team met at Camp David this week to begin to set the legislative agenda for 2018, where their focus has moved to infrastructure. While the health of our roads is important, the health of our citizens is critical. But health care must not be left by the side of the road.
“Standard of Care” therapies are as close as we come as a profession to black and white. A healthcare system which doesn’t guarantee at a minimum these standard therapies is not a system at all.
Here is one further question. Does this not represent a perversion of Parkinson’s Law? As everyone should know (look it up for its origins), Parkinson’s Law is known most commonly, as: “For complex institutions, work expands to use the resources available.” So, with access to private insurance and its indemnity cycle, a person will more likely receive the most expansive level of intervention. AND, with access to publicly funded insurance and its indemnity cycle, a person will more likely receive a less expansive level of intervention. AND, the healthcare for a person using publicly funded insurance may have levels of social adversity that become entrapped by less responsive healthcare. All very concerning since there is no itirant of our nation’s current healthcare reform to change any of this.
To further augment this argument, recall the chaotic, private insurance coverage applied to the ill-fated use of bone-marrow transplantation as a treatment for advanced breast cancer. Market share economics within our nation’s healthcare industry can be most clearly understood as a modern day version of Parkinson’s Law.