Patients in specific vulnerable population groups suffer disproportionately from cancer. The elimination of cancer disparities is critically important for lessening the burden of cancer. The Patient ...Protection and Affordable Care Act provides both opportunities and challenges for addressing cancer care disparities and access to care. The American Society of Clinical Oncology (ASCO) advocates for policies that ensure access to cancer care for the underserved. Such policies include insurance reform and the reduction of economic barriers to quality health care. Building on ASCO's prior statement on disparities in cancer care (2009), this article summarizes elements of the health care law that are relevant to cancer disparities and provides recommendations for addressing major provisions in the law. It outlines specific strategies to address insurance reform, access to care, quality of care, prevention and wellness, research on health care disparities, and diversity in the health care workforce. ASCO is committed to leading efforts toward the improvement of cancer care among the most vulnerable patients.
Directly relevant to the oncology community, Congress expanded this delegation of authority in 2008, subject to certain constraints, to cover additional preventive services under Medicare without ...explicit approval from Congress. Specifically, section 101 of the Medicare Improvements for Patients and Providers Act of 2008 granted CMS the authority to add coverage of additional preventive services if the USPSTF either "strongly recommends" (grade A) or "recommends" (grade B) the service. In addition, Congress established a requirement that CMS use its national determination process when considering whether to add such coverage for preventive screening tests. 9 Medicare's national coverage determination process, which often requires at least a year to complete, is designed to promote public input and transparency in the development of coverage policies promulgated at the national level. As a result of these changes, CMS can add coverage of new screening tests for cancer and other diseases to the Medicare program without securing explicit approval from Congress. In creating a requirement that the USPSTF recommend a preventive service prior to consideration by CMS for Medicare coverage, Congress placed great importance on the substance and timing of the USPSTF s determinations. The USPSTF is an independent panel that has operated since 1984; it is composed of non-federal primary care providers with expertise in preventive and evidence-based medicine. The Agency for Healthcare Research and Quality (AHRQ) is charged with supporting the panel's activities, and AHRQ also plays a supportive role to CMS in the context of establishing new coverage policies under the national coverage determination process. There is considerable information available on the USPSTF website regarding the composition, process, and activities of the USPSTF, including final recommendations and issues currently under review. Under a relatively new initiative, the USPSTF is providing opportunities for the public to contribute input regarding draft documents and draft recommendations promulgated by the USPSTE11 In the hope of removing a barrier to utilization under Medicare, the ACA eliminates coinsurance and deductible payments for any preventive service that Medicare covers that also is recommended by the USPSTF with a grade of A or B. In practice, this means that most but not all of the preventive screening tests currently covered by Medicare will no longer require coinsurance or deductible payments from beneficiaries. However, prostate cancer screening through digital rectal exam will continue to require coinsurance and deductible payments because this screening test does not have a USPSTF recommendation of grade A or B. Screening for prostate cancer through prostate specific antigen (PSA) testing and screening for colorectal cancer through barium enema testing would have met the same fate due to the lack of USPSTF recommendations of grade A or B; however, the coinsurance and deductible payments for PSA screening and the deductible for barium enema screening are already waived under separate sections of the Social Security Act. 19 The coinsurance payment requirement for barium enema screening for colorectal cancer remains in place. 20 The ACA makes additional changes to the coverage of preventive services under Medicare. For example, Congress clarified that certain deductible payment requirements for colorectal screening will be waived regardless of the coding used, the result of the test, or whether tissue is removed. 21 In addition, the ACA gives CMS the authority to remove or modify the coverage of preventive services previously added to Medicare by statute or otherwise if the service lacks a USPSTF grade of A, B, C (no recommendation given for routine use), or I (insufficient evidence). The coverage of PSA screening under Medicare for prostate cancer will likely provide a test for whether and how CMS may exercise this new authority. In a potential change in policy posted on October 7, 2011, the USPSTF proposed to downgrade its statement on PSA screening tests for men under the age of 75 from I (insufficient evidence) to D (not recommended). 22 This change by the USPSTF, if finalized, would trigger the option for CMS to remove Medicare coverage of PSA screening for asymptomatic men.
The Court heard arguments on whether Congress has exceeded its powers with respect to two specific provisions of the ACA. One of these provisions is the law's requirement that individuals maintain a ...minimum level of health insurance, which is often referred to as the "minimum coverage requirement" or the "individual mandate." The other contested provision is the law's expansion of eligibility and financial support for the Medicaid program, through which the federal government provides grants to state governments to help fund health insurance for the poor. In defense of the law, the Obama administration contended that two powers delegated to Congress each provide sufficient authority for the minimum coverage requirement. Immediately preceding the minimum coverage requirement in the text of the ACA itself, Congress offered its own lengthy justification of why the Commerce Clause, which is a provision in the Constitution that delegates to Congress the power of regulating commerce among the states, authorizes this individual mandate. Although the precise meaning of the Commerce Clause is a subject of frequent debate, several justices noted that its powers do have limits. For example, Justice Antonin Scalia asked, "If the government can do this, what else can it not do?" and he wondered aloud whether the ACAs supporters thought the government could force individuals to purchase broccoli. Seizing upon an aspect of the ACA that may make it unique, Justice Ruth Bader Ginsburg, later in the arguments, countered, "But the problem is ... as much as they say, 'Well, we are not in the market,' ... the uninsured haven't been able to meet the bill for cancer, and the rest of us end up paying because these people are getting cost-free health care." 5 The arguments in favor of the ACAs Medicaid expansion relied on the Taxing and Spending Clause and also on the Appropriations Clause, both of which are generally regarded as giving Congress significant discretion in dictating how federal funds are spent. However, the Court has previously indicated that Congress may not use its spending power to unduly coerce the states. The ACAs opponents argued that the Medicaid expansion is unconstitutionally coercive because it attaches new terms (ie, the requirement to cover more people) to substantial existing funds (ie, the grants the federal government already gives to the states for the original Medicaid program and its various pre -ACA expansions). Due to the size of the Medicaid program, the argument goes, the states have no real alternative but to continue participating in Medicaid under the ACAs terms. The justices discussed many sides of this issue during the oral arguments. For example, Justice Elena Kagan stated, "It's just a boatload of federal money for you to take and spend on poor people's health care. It doesn't sound coercive to me." Meanwhile, Chief Justice John Roberts observed, "I don't think you can deny that it's a significant authority that we are giving the federal government to say, 'You can take away everything if the States don't buy into the next program.'" 6 In addition to these two central questions, the Court also heard arguments on "severability," addressing whether it must invalidate all or part of the ACAs remaining provisions if it finds Congress exceeded its authority when enacting either of the provisions discussed above. In other words, the severability discussion concerns whether the Court would strike only the provision in question, only the provision in question plus some closely related provisions, or the entire ACA. The arguments on this issue mainly addressed the minimum coverage requirement and focused on the degree to which certain provisions of the ACA are linked with that provision and what Congress would have intended to occur if the provision were found unconstitutional. Congress often makes its intent regarding severability explicit, but it did not do so in the ACA.
The American Stroke Association (ASA) assembled a multidisciplinary group of experts to develop recommendations regarding the potential effectiveness of establishing an identification program for ...stroke centers and systems. "Identification" refers to the full spectrum of models for assessing and recognizing standards of quality care (self-assessment, verification, certification, and accreditation). A primary consideration is whether stroke center identification might improve patient outcomes.
In February 2001, ASA, with the support of the Stroke Council's Executive Committee, decided to embark on an evaluation of the potential impact of stroke center identification. HealthPolicy R&D was selected to prepare a comprehensive report. The investigators reported on models outside the area of stroke, ongoing initiatives within the stroke community (such as Operation Stroke), and state and federal activities designed to improve care for stroke patients. The investigators also conducted interviews with thought leaders in the stroke community, representing a diverse sampling of specialties and affiliations. In October 2001, the Advisory Working Group on Stroke Center Identification developed its consensus recommendations. This group included recognized experts in neurology, emergency medicine, emergency medical services, neurological surgery, neurointensive care, vascular disease, and stroke program planning.
There are a variety of existing identification programs, generally falling within 1 of 4 categories (self-assessment, verification, certification, and accreditation) along a continuum with respect to intensity and scope of review and consumption of resources. Ten programs were evaluated, including Peer Review Organizations, trauma centers, and new efforts by the National Committee on Quality Assurance and the Joint Commission on the Accreditation of Healthcare Organizations to identify providers and disease management programs. The largest body of literature on clinical outcomes associated with identification programs involves trauma centers. Most studies support that trauma centers and systems lead to improved mortality rates and patient outcomes. The Advisory Working Group felt that comparison to the trauma model was most relevant given the need for urgent evaluation and treatment of stroke. The literature in other areas generally supports the positive impact of identification programs, although patient outcomes data have less often been published. In the leadership interviews, participants generally expressed strong support for pursuing some form of voluntary identification program, although concerns were raised that this effort could meet with some resistance.
Identification of stroke centers and stroke systems competencies is in the best interest of stroke patients in the United States, and ASA should support the development and implementation of such processes. The purpose of a stroke center/systems identification program is to increase the capacity for all hospitals to treat stroke patients according to standards of care, recognizing that levels of involvement will vary according to the resources of hospitals and systems.
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