The American Cancer Society and the American Health Care System

Abstract

The U.S. health care system is in critical condition. Costs are rising to the point that the high price of health care is a threat to the U.S. economy. In 2010, health care was more than 17% of the gross domestic product, and if it continues to rise at current rates, health care will become more than 25% of the overall U.S. economy. This growth rate is not sustainable.

While U.S. per capita costs are the highest of any country worldwide, quality is varied. Indeed, American health care outcomes for cancer and other diseases are inferior to several European countries with far lower per capita costs.

The truth is many Americans cannot afford adequate health care, and health care is rationed in the U.S. While many do not get the health care they need, some are actually harmed by overconsumption of unnecessary health care. These Americans are treated outside of established guidelines and get unnecessary procedures and take unnecessary medications.

A substantial number of Americans are supportive of health care reform with the goal of getting needed, high-quality health care to those Americans who currently do not get it. The American Cancer Society is committed to using the established scientific methods of epidemiology to define the problems and identify possible solutions. We are committed proponents of the rational, evidence-based use of health care to avoid the wasteful and inefficient rationing of health care.

Keywords:

Health economy, Insurance, Health outcomes, Health care costs

I

ntroduction

The American Cancer Society (ACS) is a 97-year-old, nationwide, community-based, voluntary health organization dedicated to eliminating cancer as a major health problem by preventing cancer, saving lives, and diminishing suffering from cancer, through research, education, advocacy, and service. We are advocates for the health of the American public and advocates for patients. The ACS is working to reduce the rates of cancer incidence and mortality, along with measurably improving the quality of life for all people with cancer.

The ACS has a research group of epidemiologists, health practice researchers, behavioral scientists, and economists. Much of their work describes the past and present and draws a picture of the future as it relates to cancer in the U.S. and the world. We use science to set our work agenda.

The data demonstrate that:

• The U.S. health economy is in trouble, and indeed its out of control growth threatens the overall economy and the security of the country.

• The overall health outcomes of the U.S. health care system are not very good despite the potential to give the best care in the world.

• There are significant disparities in health outcomes by race and socioeconomic level that may be growing as health care gets more expensive.

Patterns of care studies show significant patterns of overuse of medicine in some populations and underuse in others. Simply put, some people are overtreated and consume unnecessary medical care. These people are even sometimes harmed by overtreatment. At the same time, a substantial proportion of Americans consume too little care, meaning necessary care is not being consumed. Through a rational approach to health care and the use of evidenced-based medicine, we could decrease health care costs and improve outcomes. We could actually improve outcomes among the insured and the uninsured. The ACS strives to be a positive influence in changing the health care system.

U

nderstanding the

H

ealth

C

are

E

conomic

E

nvironment

In the U.S., health care expenses are incredibly high. The rate of growth in health care costs is frightening and cannot go unabated. The economy simply cannot sustain it. Private and public investments, including those in key areas of the economy such as education, science, infrastructure, and defense, will undoubtedly have to be reduced to fund health care. Health care reform is a vital necessity as health care costs threaten the U.S. economy and security.

On a national level, U.S. health care costs totaled $2.53 trillion in 2009 [1]. Putting this into perspective, Americans spent nearly 2.5 times more on health care than on food in 2009. Hospital care, prescription drugs, and physician and clinical services are major costs that make up slightly less than two thirds of our health care costs. Medical imaging is an especially significant proportion of clinical services.

Health care represented 17.3% of the U.S. gross domestic product (GDP) in 2009. It was 8.8% in 1980 and 11.9% in 1990. At current rates of increase, health care will be 25% of the U.S. GDP by 2025 [2]. Health care costs are growing faster than the nation’s overall economy and faster than personal income.

The rate of increase may itself increase faster than projected above as a result of the aging of the U.S. population and the dramatic increase in obesity rates. The U.S. population aged >65 years was 30 million in 2000 and is projected to be 71 million in 2025. In the period 1975–1980, 15% of Americans were obese. This increased to 35% by 2007–2008, and continues to rise. Poor diet, lack of exercise, and weight gain will continue to increase the number of patients with diabetes, cardiovascular disease, cancer, and orthopedic injury [3]. There will also be continued advancement in medical technologies and pharmaceuticals. These are all factors that will increase medical costs in the future.

The increasing cost of health care on the economy is as startling at the individual level as it is at the national level. In 2000, an employee health insurance policy for a single person averaged $2,471; a family policy averaged $6,438. By 2009, the average for an individual was $4,824 and the average for a family was $13,375 [4]. There are 160 million employee-based health insurance policies in the U.S. Escalating health insurance costs represent a growing burden to business—especially small businesses. This clearly stifles employment.

The high cost of health care brings to mind the question of the value of health care. The per capita health care costs of most countries are 10%–12%. No other country is >12%. In 2008, the U.S. per capita health expenditure was $7,538. Norway and Switzerland were the next most expensive countries at $5,003 and $4,627 per person, respectively. Canada’s per capita cost was $4,079 [5]. The average among developed countries was $3,076. Although we are the most expensive health care system, U.S. health care outcomes are substantially below those of Norway, Switzerland, and Canada [6]. lists some commonly used assessments of health care outcomes.

Table 1.

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Among developed countries, the U.S. ranks near the bottom of virtually all major health measures. Furthermore, the quality of care in the U.S. is uneven, varying significantly across the nation by geography, race and ethnicity, and socioeconomic status [7, 8]. The U.S. has an inferior infant mortality rate and life expectancy from birth. Life expectancy from birth is lower in the U.S. than in the three countries mentioned above and, indeed, in most other developed countries [9, 10]. Our health care system is actually losing ground. Life expectancy has increased by 8.2 years in the U.S. since 1960. It has risen by 9.4 years in Canada and by >10 years in Norway and Switzerland. Some might consider the life expectancy of people who get to age 65 years as a better measure of adult health outcomes. The U.S. ranks 12th for men and 16th for women in this statistic.

The U.S. health care system can provide exceptional health care to those who can afford it; unfortunately many do not receive it. Even among some who cannot afford it, there is often overuse of health care. Much of the unnecessary care is prescribed by health care providers for a number of reasons—to satisfy the customer and keep the patient’s business, convenience, lack of understanding of the scientific evidence, and even, in some instances, greed.

U

nderstanding the

C

ondition of the

U.S. P

atient

The ACS has worked hard to draw an understanding of the effects of the high cost of health care and not having health insurance on the U.S. population. The National Cancer Database is sponsored by the American College of Surgeons Commission on Cancer and the ACS. The database covers approximately 70% of cancer patients treated in the U.S. Analysis of the data confirms that the uninsured are more likely to be diagnosed with advanced-stage, poor-prognosis disease.

Compared with those with private insurance, the uninsured are:

• More than twice as likely to be diagnosed with advanced-stage breast cancer,

• Nearly three times as likely to be diagnosed with advanced oropharyngeal cancer,

• Four times as likely to be diagnosed with advanced laryngeal cancer [ 11 12 ].

ACS intramural scientists have shown that insurance status matters even within stage at diagnosis. An insured American with Dukes B colon cancer has a higher likelihood of being alive 5 years after diagnosis than an uninsured American with Dukes A disease. Insurance coverage for all Americans is important if we are to reduce disparities [12] ( ).

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Since 2005, the ACS has document the circumstances of >16,000 uninsured and underinsured cancer patients through the Health Insurance Assistance Service (HIAS), a program of the ACS National Cancer Information Center (NCIC). Paying for cancer treatment is a significant problem for a number of cancer patients. Even those who have private insurance have often faced substantial out-of-pocket costs associated with deductibles, copays, and annual or lifetime caps [11]. Typical scenarios include:

• A woman who thought she had good insurance until she was diagnosed with stage IV breast cancer. Halfway through her scheduled chemotherapy, she was notified that she had reached her policy’s annual benefit limit for chemotherapy. Her treatment was stopped.

• A man in his 30s who is diagnosed with melanoma. He has no insurance and cannot qualify for his state’s Medicaid program. He literally cannot find treatment.

• A woman who is a 20-year breast cancer survivor who can afford only a catastrophic health insurance policy because of her “pre-existing condition.”

In early 2010, the ACS advocacy arm known as the American Cancer Society Cancer Action Network commissioned a nonpartisan study examining how families fared in the health system prior to implementation of the Affordable Care Act (health care reform) [11].

Key findings were:

• High health costs jeopardize the ability of families affected by cancer to afford the care they need. Half of the families with someone aged <65 years with cancer (49%) say they have had difficulty affording health care costs, such as insurance premiums, copays, and prescription drugs, in the past 2 years.

• High health costs also prevent people with cancer and their families from affording basic necessities. In the past 2 years, nearly one third of families with someone aged <65 years with cancer (30%) have had trouble paying for basic necessities or other bills, and 23% have been contacted by a collection agency. About one in five (21%) has used up all or most of their savings, and one in six (18%) has incurred thousands of dollars of medical debt.

• Affordability of care is a major issue for people aged <65 years, and for those most in need. As a result of costs, one in three individuals aged <65 years diagnosed with cancer (34%) has delayed needed health care in the past 12 months, such as putting off cancer-related tests or treatments, delaying cancer-related checkups, not filling a prescription, or cutting pills. Of those currently in active cancer treatment, one in three (33%) has put off some type of health care in the past year because of costs.

• People with cancer and their families struggle to stay insured. One in three families (34%) with someone aged <65 years with cancer says that person has been uninsured at some point since their diagnosis.

• The costs of coverage continue to rise. Four in 10 families (42%) with insurance say their premiums and/or copays have increased in the past 12 months for the family member with a cancer diagnosis, and one in four (25%) says his or her deductible has gone up.

The data demonstrate that health care rationing is occurring. A substantial proportion of the uninsured and underinsured are unable to get the adequate health care that they need. Ironically, one major driver in health care costs is overconsumption of health care. A substantial amount of health care that is provided and consumed in the U.S. is excessive care resulting from inefficiencies in the health care system. Some excessive care that is given does not meet an evidence-based standard. At times, excessive care, such as extra radiologic imaging studies, is given simply because the patient’s complete medical record is not available.

T

he

ACS C

ommitment

In 2006, the ACS national board adopted as a principle that every American should have access to affordable, adequate health care.

The availability, affordability, and adequacy of health coverage for all Americans cannot realistically be achieved if the rising costs of health care cannot be reasonably—and rationally—constrained. To contain costs in the long run, our nation’s health care system must be reoriented to emphasize wellness and healthy outcomes. Although there is disagreement on how to achieve that goal, there is a general recognition that incentives and approaches to delivery of health care have to be realigned to give greater focus to outcomes and patient well-being.

The ACS is committed to education of the public and the cancer patient about healthful habits and good treatment. While recognizing the importance of providing good treatment to all who are sick, we hope to be a part of transforming the health care system away from its current heavy emphasis on reacting to and treating illness toward a system that puts high value on prevention of illness. Given the shifting population demographics in the U.S., prevention of disease is of paramount importance. Over the last several years the ACS has partnered with the American Heart Association and the American Diabetes Association because these three diseases have common causes and common prevention.

The ACS supports the wise use of medicine. We advocate for the rational use of medical care in order to reduce the rationing of medical care. Society needs to appreciate the body of scientific and medical literature showing what prevention and treatment interventions are proven effective and how often those effective measures are not practiced. Thousands of American lives are lost daily because these Americans are unable to benefit from current medical knowledge.

The ACS is an advocate for science. We support the development and use of evidence-based medicine. Today, much of the practice of medicine is opinion of the individual physician. Comparative effectiveness research (CER) has the potential of finding more effective treatments at a lower cost. Some CER has already been done in oncology under a different name, the large phase III randomized trial. The guidelines of the National Comprehensive Cancer Network are often based on assessment of these trials. These guidelines are highly regarded but often not used.

The ACS convenes groups of unbiased experts to review the scientific literature and produce cancer prevention and screening guidelines and recommendations based on what is shown to save lives using accepted scientific principles [13]. These guidelines are highly respected, but often not practiced. Nearly half of all adults aged >50 years have never been screened for colon cancer, yet stool blood testing at a cost of $10 a year has been shown to reduce the risk for colon cancer death by ≥35%.

Numerous studies, some supported or conducted by the ACS, show that the medically underserved have greater difficulty accessing cancer screening and prevention [14]. If symptomatic, they have greater difficulty getting evaluated and diagnosed. They usually have disease detected at a later stage. If diagnosed, they have greater difficulty getting adequate treatment. Some of the difficulty is simply affording care, but there are other reasons for poor outcomes such as lack of transportation to health care facilities, poor health literacy leading to noncompliance, and fear of the medical system [15].

Some reasons for the higher costs of U.S. health care include the large number of patients presenting with serious diseases late and the overuse of emergency rooms by patients who do not have a relationship with a physician. The “medical home” concept, if fully implemented, has the potential to decrease the misuse of emergency departments. Every person, even the healthy, is assigned a physician. The medical home concept increases emphasis on prevention of disease.

The ACS has instituted programs to assist cancer patients. The HIAS works to help patients find needed funding. There are transportation and navigation programs to improve adherence to treatment. The NCIC is available by internet or 800 number 24 hours a day, 7 days a week. It has publications and programs to increase health literacy.

S

ummary

The U.S. health care system is troubled by the excessive expense of health care, and health care costs continue to rise. The increasingly high cost of health care is making health insurance more expensive and decreasing the number of Americans covered by insurance. Substantial portions of the insured eventually find themselves underinsured, and a disproportionate number of racial/ethnic minorities are socioeconomically disadvantaged and negatively affected by the high cost of health care. The extremely high cost of health care contributes to racial/ethnic health disparities and also creates a class of Americans in the majority middleclass who have disparate outcomes.

The excess health care costs in the U.S. do not translate into better outcomes. Overall, U.S. outcomes are not especially better than most other developed countries. Commonly accepted measures of outcome include the infant mortality rate and life expectancy. The U.S. has cancer mortality rates similar to those in Canada, Switzerland, and other western European countries. These are all countries where per capita health care costs are significantly lower than in the U.S.

The ACS is a vocal advocate for rational, high-quality, evidence-based use of medicine. We have a vibrant cancer control program that convenes panels of unbiased experts to assess clinical and epidemiologic data and write guidelines and recommendations concerning cancer prevention and screening. The ACS health promotions activity stresses public education about cancer prevention and patient education about quality treatment. Our advocacy group promotes transformation of the current health care system as well as support for cancer research, including research on payment reform.

It is only through stressing quality, efficient health care and having an open mind toward change that we can control costs and reach all Americans in need of health care. We should be concerned about the rational use of health care to prevent further rationing of health care.