Leonard Lichtenfeld, MD: There are obviously a lot of political issues surrounding the ACA. One of them is the eligibility question—that is, when people come into the system and they may have a job, and this is what happened to cancer patients. They have a job. They try to keep their job. Their insurance comes with their job, and they lose their job. And somebody says, you can go on COBRA (Consolidated Omnibus Budget Reconciliation Act). I don’t know if you’ve ever priced out COBRA. COBRA is not exactly an inexpensive policy for many people who have employer-based insurance. So, they fall off the insurance rolls. We would like to see, and I would like to see, a better ability for people to transition into coverage.
One of the problems is that whoever certifies—people who are eligible to go into the ACA because of a life event like cancer—can get it quickly without a lot of hassle. A number of years ago, we did something with Social Security, where Social Security had patients’ disability but had a long waiting time for everybody who applied for Social Security disability. And the Commissioner took it upon himself—well, it was obviously with a lot of consultation—to move forward with a diagnosis-based a priori: a decision that on its face, was appropriate. So, if somebody had pancreatic cancer, they could get into the disability system quickly, as opposed having to wait an interminable period of time. That system of getting people onboard is important.
From a personal point of view, I wish the deductible issue could be faced. People in poor communities—a lot of them don’t have the money. In fact, in the entire country, a lot of people don’t have the savings to pay for those deductibles. I’m not sure if there’s an easy answer to that one, but it’s something that we need to recognize—that there are a lot of care situations where people need the care and they can’t pay for the care. And with medicine being the way it is today, one of the things we see happening, developing, and evolving is that more health professionals and more hospitals—everyone—want their money upfront. There is no easy answer to that one.
Access to care is the other piece, and this is not necessarily a legislative issue, but a lot of people have insurance for the first time in their lives. We need to help people understand. We were talking, in a previous discussion, about genomics and education for genomics in the population. What about people who don’t even know how to take care of themselves? And that’s not a negative; it’s just a reality. What about various communities that may have English as a second language that don’t know what’s available? How are we going to address that issue? How are we going to take people who live in communities where you know there may be other side issues?
It may not be drugs, but it may be violence, and there’d be questions. How do we get them from their communities? How do we get the care into their communities? Those are all issues that we have to address. Now, that’s not necessarily an ACA issue, but it’s the kind of issue we need to be talking about as a country. We need to start talking about the people, and we need to talk about systems of care. And then we’ve got to figure out how we are going to pay for that because it’s not going to come from charging for an office visit.
There’s a coming expectation that the medical—particularly the primary care—system is about to expand beyond taking care of your blood pressure or your diabetes. It needs to move more into the social arena as well. You can’t layer that on top without having a system of care that’s flexible, adaptable, responsive, and paid for.