1. The Health Insurance System from the Patient’s Perspective
Stephen Finan
October 3, 2008

2. Adequacy Inadequate = Underinsured Complete continuum
Adequacy means a cancer patient would have access to the full range of treatment without imposing a financial burden
Complete continuum
of evidence-based
cancer care
Doreen’s struggle
with inadequate
insurance
coverage
Adequate health insurance…
Ensures timely access to the full range of evidence-based health care services (i.e., rational, science-based, patient-centered) - including prevention and primary care - necessary to maintain health, avoid disease, overcome acute illness, and live with chronic illness. These services include the complete continuum of evidence-based cancer care for treatment and support needs including clinical trials. Coverage should be comprehensive, not run out, and fully cover catastrophic expenditures.
Doreen from New York
Doreen, a 57 year-old former medical office receptionist, was diagnosed with Stage IV breast cancer in the fall of The cancer metastasized to her spinal column, liver, lungs, and left femur. Doreen and her husband, a retired New York City police officer, have health insurance through his retirement plan. The insurance covers 30 outpatient visits a year, a number Doreen quickly exceeded after beginning treatment for her cancer. After she reached this annual limit, she was billed $5,000 a week for chemotherapy treatments. In less than a year, Doreen and her husband owed more than $100,000 to the hospital for her treatment. By the time Doreen's insurance company informed her that she had exceeded her maximum number of outpatient visits, she had already made additional visits the plan would not cover. Fortunately for Doreen, she spoke at an American Cancer Society event about her inadequate insurance and the story ran in the Long Island Newsday. Upon reading the article, the insurer reversed the decision and paid Doreen’s medical bills in full. While Doreen’s story turned out well, countless others are not as fortunate to have a platform to share their story.
It was stories like Doreen’s and the countless stories of uninsured Americans’ struggle with this dreadful disease that brought the American Cancer Society to the conclusion that we had to enter the broader national debate about access to care.

3. Availability Everyone has to get in Must not be constrained by
Renewable
Portable
Continuous
Must not be
constrained by
health status
No health insurance
options available for
Margaret
Available health insurance…
Is renewable, portable, and continuous. It must not be based on, or constrained by, actual or perceived health status or history of health care services use.
Margaret from Georgia
Margaret, 52, had been working for a small tile and granite supply company until she was laid off in May At about the same time, the employer stopped offering health insurance because of costs. Not only did Margaret lose her job, she lost her health insurance.
About a year prior, Margaret was diagnosed and treated for stage III ovarian cancer. Her doctors recommended Margaret have follow up visits every 3 months along with her port flushed every 6 weeks. Since Margaret lost coverage unexpectedly, none of the claims she made after May 31 were covered and she currently has more than $4,000 in outstanding bills.
When Margaret’s employer stopped offering health insurance to employees, Margaret became HIPAA eligible, but she was not aware this protection and missed the election window. The individual market is medically underwritten and Margaret has received several denials for coverage. She applied for Medicaid but was denied based on her income. For Margaret, no opportunities for health insurance exist.

4. Affordability Based on ability to pay
Premiums should not be based on health status
Reasonable out-of-pocket costs, including co-pays and deductibles
Jaqueline used all her savings to cover co-pays, co-insurance, and other expenses not covered by her health insurance
Affordable health insurance…
Provides everyone the ability to purchase meaningful private health insurance based on his or her ability to pay. Premium pricing should not be based on an individual’s actual or perceived health status or history of health care services utilization. Annual total out-of-pocket costs (includes co-pays and deductibles) must be reasonable.
Jacqueline from Maryland
Jacqueline, 55, is insured as a dependent on her husband’s employer-sponsored insurance coverage (Cigna PPO). In August 2005, Jacqueline was diagnosed with stage III C breast cancer (HER2/neu and estrogen receptive positive) and cost sharing for her plan became a major financial burden for the Jacqueline and her husband. She had a bilateral mastectomy, chemotherapy, and radiation. In addition to this, Jacqueline developed lymphedema and had to have some of her lymph nodes removed along with physical therapy and special compression garments. Jacqueline's medical bills and co-payments have almost completely depleted their savings account, an estimated $50,000.
"I'm in physical therapy three times a week, I still see the doctors, the MRIs, the CAT scans, everything continues, you know, the bills are still ongoing, so we haven't had a break since the time I was diagnosed," she said.
Her family's savings is almost gone.
Many families like the Eylers are left staring at bills, hoping to get well without going broke.

5. Administrative Simplicity
Transparency and simplicity in private health insurance products
Can the policy be
understood?
By the patient
By the provider
Maggie’s inability
to navigate the
complexities of the
health insurance
continues to cost
her dearly
Administratively simple health insurance…
Requires transparency and simplicity in private health insurance products, both pre and post enrollment. Covered benefits, financial liability, and terms for making claims must be clear. Consumers must be able to compare and contrast different health insurance plans and easily navigate health insurance transactions and transitions.
Maggie from Indiana
Maggie gave up her individual health insurance coverage after she was unexpectedly charged $4,000 in medical expenses. Her plan included a caveat where medical tests weren’t covered if surgery didn’t follow within 90 days. Because of the unexpected expenses, Maggie could not afford to maintain her coverage and became uninsured. This confusion left Maggie uninsured when she received her cancer diagnosis.
Maggie was treated for bladder cancer. Her doctor advised that she should receive regular follow-up tests after her treatment. However, this wouldn’t be possible unless she obtained health insurance again. Having already struggled to navigate the complexities of health insurance, Maggie called the American Cancer Society to examine her coverage options.
Maggie applied for Medicaid, but she was denied. Meanwhile, an individual policy wouldn’t meet her needs. Indiana allows for medical underwriting, a process where applicant risk is factored into coverage decisions. Considering the recurrence rate of bladder cancer, Maggie was a high-risk applicant. Even if she received coverage her cancer treatments would be excluded as a pre-existing condition.
A final option presented by an ACS Cancer Information Specialist was Indiana’s high risk pool, the Indiana Comprehensive Health Insurance Association. The pool covers individuals who are denied health insurance. However, Maggie would face a three month pre-existing exclusion period, and the monthly cost once she received coverage would exceed her limited means.
Maggie’s inability to navigate the complexities of the health insurance market continues to cost her dearly.

6. Eliminate “Cherry Picking”
Also known as Segmentation
If insurers insure only those who are healthy, the costs of insurance can be unaffordable or even unavailable for others A
Does the reform plan reduce or eliminate the ability of insurers to “cherry pick” among applicants?
Limiting “cherry picking”… also known as “segmentation,” to prevent discrimination against individuals with health risks or perceived health risks. If insurers insure only those who are healthy, the costs of insurance can be unaffordable or even unavailable for others. A A A

7. You’ve reached the end of the policy issue training on Access to Care
You’ve reached the end of the policy issue training on Access to Care. Thank you for listening to this training.