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A "Hidden Crisis" For a Growing Number of Cancer Patients

By Cancer Care, Inc.

In the United States today, there are an estimated 6 to 7 million people living with cancer. But for a growing number, it is the status of their insurance -- and not the status of their health -- that will determine what medical treatment is available to them. Medical insurance, often thought to exist for such "emergencies" as a catastrophic illness, has become for some a barrier to life-saving care. For a cancer patient, it can be a "hidden crisis" of their diagnosis.

Inadequate Insurance: One Patient's Story

When 42-year-old Cancer Care patient Marsha Simmons (not her real name) found out she had breast cancer, she followed what is now a routine course of treatment: she had a the lump in her breast removed surgically, and began radiation therapy on an out-patient basis at a clinic. But when Marsha submitted claims to her insurance company, she learned her particular policy would cover only in-patient (meaning "in-hospital") treatment. Despite having a good job and an active insurance policy, Marsha without coverage for her cancer-related medical bills.

Unable to be admitted to a hospital to continue radiation treatment, Marsha decided to continue going to the clinic. She felt she had no other choice. After several months of letting her medical bills pile up, Marsha applied for Medicaid (the government medical entitlement program for low-income people). Even though her outstanding bills almost equaled her annual salary, she was told that she did not qualify. Out of options, Marsha and her husband filed for personal bankruptcy. But she still had no way to pay her medical bills. And Marsha still needed to undergo the final, chemotherapy stage of her treatment.

Cancer Care was able to locate a clinic with a sliding scale where Marsha could receive chemotherapy she could afford and, through a special grant, helped her with some of her bills. But many cancer patients are facing the same situation as Marsha -- finding out only after they are diagnosed, after they have made treatment choices, or in the worst case, after they have been treated, that their insurance will not cover their bills.

Who Has Insurance, What Kind Do They Have, and Why Is There a Problem?

A majority of Americans, either for themselves or through a family member or spouse, do have some form of insurance. Most -- about 60% -- are covered by private group insurance, the kind offered by many companies to their employees. Another small percentage have individual private insurance, and Medicare and Medicaid, the two largest government entitlement programs, provide for about 20% more. The remaining 15% -- almost 135 million people -- are without insurance. However, most of these people are not unemployed or desperately poor, as is usually thought. More often, they are self-employed, work where they cannot get insurance, or are children not covered by a parent's policy.

With the presidential elections coming at the end of this year, there has been much public discussion lately concerning the problems of private insurance, and the medical health care system as a whole. Yet most proposals for reforming insurance focus on bringing helping. Those who are now without any medical benefits whatsoever. What is being overlooked, many experts feel, is the rising number of problems among those who already have insurance. Many are finding their insurance coverage to be an poor financial safety net if they fall severely ill.

The Problem in Three Parts

Although complicated, the 'insurance crisis' can be broken into three basic parts -- medical care, insurance, and the patient:

Medical Care: The cost of medical care has risen dramatically in the last decade, and shows no signs of slowing. This has had a major impact on the health care provision itself, and on medical insurance.

Insurance: While it offers adequate coverage for a great number of people, the current system of employer-based insurance does have gaps; due to rising medical costs, they appear to be widening faster than anticipated.

The Patient: Until they are faced with a serious illness, many people do not know what their medical insurance will cover. Sometimes they are not fully aware of the tremendous costs that can accompany care. Cancer patients -- often in need of intensive and sometimes lengthy medical care -- are often the most vulnerable.

Medical Costs: The Driving Force Behind the Insurance Crisis

While there is a general disagreement about how to go about solving each of these problems, experts are in agreement about which is the most important: the skyrocketing cost of medical care itself.

Health care costs in the U.S. have nearly tripled since 1980, and are currently increasing at a rate of about 10% per year. Most people think they will double again before the year 2000. The bill for the nation's health care last year was $743 billion dollars; for cancer-related treatment alone, it was $104 billion. Aside from costing more, the percentage spent on health care as a portion of Gross National Product is also growing.

While the rise in health care cost is due to several factors, two trends are usually considered the most important: an increase in the average age of the U.S. population over the last two decades, and the dramatic growth in medical technology that has occurred during that time as well. Other factors include the rise in malpractice suits (which has increased the cost of primary care) and a steady growth in the number of uninsured who require care in U.S. hospitals (which has forced these institutions to charge paying patients more).

The Effect on Insurance Coverage: More Expensive and Less Comprehensive

The overall rise in most of medical care has had a direct impact on the cost of private insurance; for both companies and their employees, the rates have risen almost as fast, if not faster, than those of health care. A recent nationwide survey showed that the average cost increase of employee-provided private insurance to employers was about 12% annually -- almost four times the rise in overall living costs. Projections for 1992 ran even higher, with some forms of coverage expected to go up 20 percent.

This has greatly affected the ability of employers to provide insurance for employees. And not surprisingly, it has had the largest impact on small businesses, who are often less able to afford health insurance to begin with.

To try to cope with these rising costs, some companies have passed a portion of it on directly to the employees, through an increased payroll deduction for insurance. Others have changed to less expensive insurance policies, which are also less comprehensive -- they pay back lower amounts on claims, and cover less. All too frequently, some smaller businesses have been forced to drop coverage altogether. With more than half of the American workforce employed by small businesses, the number of people affected could be extremely high. Some estimate that by 1994, one worker in four will lose his or her insurance.

How This Affects Cancer Patients

It is important to note that insurance companies are not solely to blame -- in many ways, they are as much a victim of rising medical costs as the patient. Yet, in addition to raising their rates, many insurers have also changed their policies in ways particularly harmful to cancer patients.

For example, some insurance companies now have a limit on the renewability of their policies; this allows them to exclude any group they consider to be a "high-risk" when the policy is renewed. Obviously, cancer patients can fall into this category. Another common approach has been to place a "lifetime cap" on the policy -- an upper limit the insurance company will pay out over the lifetime of the insured person. In this case, insurance coverage may run out before an expensive or lengthy cancer treatment is completed.

And particularly damaging for cancer patients, some companies have now extended the waiting period of their new policies -- the time during which they will not pay costs that relate to a pre-existing health condition. A one- or two-year waiting period can leave a cancer patient without any form of cancer-related medical coverage during that time.

Changes in Cancer Treatment

Because of a rise in early detection and improvements in treatment, cancer is no longer an acute disease but a chronic one: people diagnosed with cancer now have a higher recovery rate, live longer, and more treatment is being performed on an outpatient basis. However, this has made them more vulnerable to shifts in private and public insurance coverage, and placed a greater financial burden on the family.

For cancer patients, like Marsha Simmons, a loss of insurance can be devastating. Cancer Care has helped many patients for whom insurance coverage is the largest factor in determining medical treatment. As difficult as it may be to believe, some patients have been forced to choose less effective treatment, or even postpone or cancel treatment altogether, due to lack of insurance coverage and a lack of funds for direct payment.

In the case of almost every cancer patient, there is a large financial burden that accompanies medical care. Even for those who have adequate insurance, the added strain of not knowing whether an expensive and life-saving treatment will cease due to an insurance problem can seriously impair a patient's focus on getting well.

How Insurance Affects Work after Treatment

Most cancer patients today are able to resume working after undergoing treatment. While this allows them to keep their insurance coverage, it can also create "job-lock", where they are "locked" into a position because they cannot get insurance anywhere else. Cancer, as a pre-existing medical condition, would make them ineligible for the new policy that would accompany a new job.

Job-lock can be particularly trying for anyone who had cancer in the past but who is now recovered. Some insurance companies have a "look-back" period of up to 20 years, meaning any illness within that time can qualify as a 'pre-existing condition' and not be covered. A person with cancer at almost any time in their background may be considered uninsurable.

Insurance may also affect how an employer views a cancer patient after he or she returns to work. Employers, who sometimes must pay higher premiums for the ill employee, may pressure that person to leave. Also, many jobs are not flexible enough to permit time off for treatment or extended illness. If they also must pay money for disability, an employer may exert subtle or not-so-subtle efforts to get the ill person out. Fellow employees may also harbor resentments and make it difficult to work.

What Can a Cancer Patient Do?

While there is no law in the U.S. that guarantees insurance for all forms of illness, there are several steps a cancer patient can take to guard against an insurance crisis. The most important one is to find out as much as possible about your current policy or policies, and to be informed as to what your rights are. If you leave your job for any reason, you are legally entitled to keep your group insurance for a period of time depending on the size of your company and the type of insurance you have.

There are also several groups that provide information about insurance. Each state has a Department of Insurance, which can help inform you of your rights in your state. Laws affecting health insurance are largely state laws.

A call or letter can help you understand what your present and future insurance options are, and help you avoid the mistake of assuming that everything will be paid for by your insurance company. The sooner you know about your options, the better you will be able to make informed decisions about how to go about getting the right kind of care.

This article brought to you by Cancer Care. For more information see the Cancer Care web site http://www.cancercare.org or contact them directly at 1-800-813-HOPE.

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