From Cancer Patient to Cancer Survivor Lost in Transition (2006) / Chapter Skim
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6 Employment, Insurance, and Economic Issues
6 Employment, Insurance, and Economic Issues
Pages 363-433
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From page 363... ...
The extent of these socioeconomic problems and current legal remedies to address them are described in this chapter, as are potential programmatic, educational, legislative, and advocacy responses.1 Selected federal and state programs are described that are relevant to cancer survivors, including the Medicare prescription drug program that will be implemented in 2006; a state Medicaid option available since 2000 to provide poor and uninsured women with coverage for treatment and follow-up of breast and cervical cancer; recent federal investments in state high-risk insurance pools that provide insurance coverage to people who cannot get insurance because of poor health; and federal income replacement programs through the Social Security Administration for individuals too disabled to work. 1This chapter is based, in part, on a background paper prepared in 2002 by Barbara Hoffman for the National Cancer Policy Board, Policy Recommendations to Address the Employment and Insurance Concerns of Cancer Survivors.
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From page 364... ...
. Retaining one's employment status has obvious financial benefits and is often also necessary for health insurance coverage, self-esteem, and social support (Voelker, 1999; Spelten et al., 2002)
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Most companies used to pay health benefits for the long-term disabled until they were 65, but as health insurance costs and the number of disabled employees have climbed, more com panies are firing them. According to a survey of 723 companies in 2002, 27 per cent had a policy to dismiss employees as soon as they went onto long-term dis ability and 24 percent dismissed them at a set time thereafter, usually 6 to 12 months.
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From page 366... ...
5. Identify moderators of work return and work function, particularly those that are susceptible to intervention (e.g., availability of health insurance and disability benefits to offset lost income)
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. The implication of these findings is that interventions to assist survivors who stop working (e.g., income replacement programs, information about access to health insurance)
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From page 368... ...
Relatively few studies have examined the effect of cancer on income in the context of the family household. In one study that studied such effects, breast cancer survivors who were working at the time of their diagnosis experienced higher rates of functional impairment and significantly larger reductions in annual earnings over the 5-year study period than did working control subjects.
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From page 369... ...
Using multivariate analyses to control for potentially confounding factors (i.e., age, sex, race/ethnicity, educational attainment, health insurance status, and marital status) , individuals with cancer but no other chronic disease were found to be three times more likely to be unable to work than individuals without a history of cancer and reporting no chronic illness.
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From page 370... ...
370 FROM CANCER PATIENT TO CANCER SURVIVOR 5.0 2.8 2.5 9.1 11.6 3.2 16.8 19.8 4.8 5.9 7.4 8.3 Unable to work 94.7 Limited Percentage 91.8 82.5 86.1 None 75.8 71.9 All 18-44 45-64 All 18-44 45-64 Cancer History No Reported Cancer History Age and Cancer History FIGURE 6-1 Work limitations by age and self-reported history of cancer, 1998 2000. SOURCE: Hewitt et al.
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From page 371... ...
In addition to medical costs that may be borne by employers, there are concerns about absenteeism from work, disability program use, workers' compensation program costs, turnover, family medical leave, and on-the-job productivity losses. Consequently, the cost of cancer to employers greatly exceeds the cost of health insurance alone (Lee, 2004)
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From page 372... ...
For example, infections, asthma, and dental procedures, although not immediately thought of as being associated with cancer, cost considerably more among cancer patients than controls. In summary, a number of studies have been conducted to gauge the effect of cancer on employment.
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From page 373... ...
, and the Federal Rehabilitation Act -- provide cancer survivors with some protection against employment discrimination. Americans with Disabilities Act The Americans with Disabilities Act of 1990 prohibits certain employers from discriminating against individuals with disabilities (see Box 6-2)
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What is the ADA? Title I of the Americans with Disabilities Act of 1990 prohibits private employ ers, state and local governments, employment agencies, and labor unions from discriminating against qualified individuals with disabilities in job application proce dures, hiring, firing, advancement, compensation, job training, and other terms, conditions, and privileges of employment.
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From page 375... ...
Other courts have followed the reasoning of the Fifth Circuit and rejected lawsuits by cancer survivors. In another case, a long-term survivor of non-Hodgkin's lymphoma, fired because his employer feared that future health insurance claims would cause his insurance costs to rise, was determined not to be covered under the ADA after his dismissal (Hirsch v.
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From page 376... ...
Cancer survivors who need extra time or help to work are entitled to a "reasonable accommodation." Common accommodations for cancer survivors include changes in work hours or duties to accommodate medical appointments and treatment side effects (Box 6-3)
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Employers may not assume that an employee's job performance would be affected by the need to care for a family member who has cancer. An important exclusion of the Americans with Disabilities Act is contractual employees.
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From page 378... ...
. Family and Medical Leave Act The Family and Medical Leave Act enacted in 1993 requires employers with at least 50 workers to provide certain benefits for serious medical illness, including cancer, for employees or dependents (U.S.
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From page 379... ...
Some employers fear that the participation of a cancer survivor in a group medical plan will drain benefit funds or increase the employer's insurance premiums. An employer may violate ERISA if, upon learning of a worker's cancer history, it dismisses that worker to exclude him or her from a group health plan.
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From page 380... ...
State Employment Rights Laws All states except Alabama and Mississippi have laws that prohibit discrimination against people with disabilities in public and private employment (Hoffman, 2002, 2004b) .9 Several states, such as New Jersey, cover 9 Alabama and Mississippi laws, which have not been amended since the 1970s, cover only state employees.
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From page 381... ...
The rights of cancer survivors in states whose laws do not mirror the ADA vary depending on how those laws define the protected class. Many states have leave laws similar to the federal FMLA in that they guarantee employees in the private sector unpaid leave for pregnancy, childbirth, and the adoption of a child (see Box 6-5)
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From page 382... ...
Some employers and co-workers treat cancer survivors differently from other workers, in part because they have misconceptions about survivors' abilities to work during and after cancer treatment (NCCS and Amgen, undated)
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3. Evaluate whether health plan benefit design provides for adequate treat ment and supportive care for cancer patients.
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Cancer voluntary organizations and consumer advocacy programs Several nonprofit cancer organizations provide education, counseling, and legal advice regarding employment to cancer survivors. The American Cancer Society (ACS)
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From page 385... ...
Cancer Legal Services Project of the Bar Association of San Francisco provides free services directly to low-income people with cancer. Legal Advocacy for Cancer Patients at the Temple Legal Aid Office pro vides free attorney and advocate services to individuals in Philadelphia.
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From page 386... ...
Associated with Stanford University Medical Center, the program provides entrepreneurship resources for cancer survivors and educational programs for business and governments (Good Health for Life, 2004)
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From page 387... ...
This section briefly reviews these programs. Sources of financial assistance for individuals' health-related expenditures are described in the next section of the chapter following a review of health insurance issues.
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. Federal Social Security Administration programs Since 1974, the Supplemental Security Income (SSI)
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In December 2003, an estimated 53,376 individuals under age 65 were receiving SSI benefits because of a diagnosis of cancer. Cancer survivors represent only 1.1 percent of the total number of SSI recipients under age 65 (4.9 million)
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HEALTH INSURANCE The Impact of Cancer on Health Insurance Cancer care is very costly and represents one of the three most expensive conditions in the United States (Cohen and Krauss, 2003)
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Three-year relative cancer survival was markedly poorer for those without health insurance as compared to the insured, according to one state's populationbased study (Grann and Jacobson, 2003; McDavid et al., 2003)
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From page 392... ...
Only through such an effort will cancer survivors, their families, and health care providers be able to fully focus on care and well-being without being burdened by financial worries. Although addressing national health care proposals to extend health insurance coverage to more Americans was not within the scope of the Committee on Cancer Survivorship's work, the committee wishes to highlight in this report the serious consequences of lack of insurance coverage to cancer survivors, their families, and their caregivers.
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From page 393... ...
Next, problems of cancer survivors with insurance are reviewed, including difficulties in maintaining health insurance coverage, gaining access to needed treatments and specialists, and paying health care out-of-pocket costs that stem from underinsurance (either due to insurance exclusions or benefit limits)
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From page 394... ...
cancer survivors aged 65 and older have health insurance coverage through the nation's Medicare program.12 The problems the elderly have in coverage are discussed in the next section. With 39 percent of cancer survivors under age 65 and the potentially devastating impact of a cancer diagnosis on personal finances, the committee analyzed data from the National Health Interview Survey (NHIS)
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4. How does the health insurance status of cancer survivors compare to that of the general population and to individuals with other chronic illnesses?
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. This could be explained if there is overreporting of a cancer history among those ages 25 to 64 and interviewed for the NHIS.
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EMPLOYMENT, INSURANCE, AND ECONOMIC ISSUES 397 Health Insurance Status (percentage distribution) Other Medicare Medicaid Private Coverage Uninsured 7.4 6.8 70.6 3.9 11.3 3.5 9.2 65.3 3.6 18.5 9.1 5.8 72.9 4.1 8.2 10.5 5.1 70.9 5.2 8.3 6.0 7.6 70.5 3.4 12.6 7.1 5.8 73.2 4.0 10.0 -- 10.2 56.4 -- 25.8 10.0 14.1 56.0 -- 15.0 -- -- 52.5 -- - -- 6.4 76.0 -- 7.9 6.3 6.5 75.2 -- 9.5 8.3 7.1 68.7 4.3 11.5 8.8 7.2 67.1 -- 13.1 7.6 7.1 66.3 -- 14.7 3.3 9.3 65.3 3.5 18.6 7.9 6.3 71.4 3.4 11.0 9.9 5.5 74.3 4.4 5.9 6.3 5.1 80.2 -- 5.4 4.9 10.6 61.8 4.0 18.7 -- -- 80.0 -- -- - -- 72.0 -- - 9.4 5.5 71.1 3.8 10.2 15.2 11.2 56.2 5.3 12.1 3.1 4.5 78.3 3.2 10.9 -- -- 84.2 2.6 10.2 4.0 5.6 74.6 3.7 12.1 20.1 15.9 45.6 6.2 12.1 aFemale reproductive cancer includes cancer of the cervix, uterus, and ovary.
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From page 398... ...
Limited access to public insurance coverage Medicaid, the leading safety net program for health insurance coverage, is not available to millions of uninsured poor Americans. Only certain categories of people are eligible for Medicaid: children, parents of dependent children, pregnant women, the elderly, and the disabled.
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. The three "A's" barriers facing cancer survivors in the individual health insurance market are well illustrated by a study commissioned by the Kaiser Family Foundation.
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More than half of the states operate high-risk insurance pools to help provide coverage to individuals with serious medical conditions who have been denied private health insurance in the individual market (Achman and Chollet, 2001; Abbe, 2005)
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From page 401... ...
In the 109th Congress, legislation has been introduced to reauthorize $15 million in seed grants for fiscal years 2005 and 2006 for states launching high-risk insurance pools and to provide $75 million in grants for fiscal years 2005 through 2009 for states that currently operate high-risk pools (State High Risk, 2004, 2005; Kaiser Family Foundation, 2004c)
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From page 402... ...
Federal law mandates coverage for reconstructive surgery and these survivorship-related services in health plans that cover mastectomy. Maintaining health insurance coverage For cancer survivors who lose their jobs, the federal law known as COBRA mandates that they can keep the health insurance they had through their employer for 18 months.13 Some 13The Consolidated Omnibus Budget Reconciliation Act of 1986 (Pub.
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From page 403... ...
14 to improve the portability and continuity of health insurance coverage in private insurance markets and among employer-sponsored group health plans. For people changing jobs, HIPAA added important protections.
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. Foremost among these is the HIPAA eligibility requirement that individuals have elected and exhausted COBRA benefits and the high costs associated with premiums.15 Inadequate health insurance coverage Consumer cost sharing has increased greatly in recent years, placing a larger financial burden on those with insurance.
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From page 405... ...
The "cancer health effects" group does not necessarily include all cancer survivors; cancer survivors who do not experience adverse cancer-related health effects would not be included. Expenditures include both spending for care directly related to cancer and spending for other medical care unrelated to cancer (see Appendix 6A for a description of the Medical Expenditure Panel Survey and the methods used to derive these estimates)
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From page 406... ...
The "cancer health effects" group does not necessarily include all cancer survivors; cancer survivors who do not experience adverse cancer-related health effects would not be included. Expenditures include both spending for care directly related to cancer and spending for other medical care unrelated to cancer (see Appendix 6A for a description of the Medical Expenditure Panel Survey and the methods used to derive these estimates)
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From page 407... ...
. Some cancer survivors with health insurance lack coverage for needed care.
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For example, health insurance coverage of prophylactic mastectomy and oophorectomy varied in one study, with only 44 percent of private plans surveyed having specific policies for coverage of prophylactic mastectomy for patients with a strong family history of breast cancer and 20 percent having a policy for coverage of prophylactic oophorectomy under any clinical circumstance (Kuerer et al., 2000)
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From page 409... ...
. Because so many cancer survivors have health insurance coverage through the federal Medicare program by virtue of their age, its coverage policies are of particular interest.
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belongs to the family of drugs called antiestrogens and blocks the effects of the hormone estrogen in the breast. It is used to treat breast cancer, and to prevent it in women who are at a high risk of developing breast cancer.
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From page 411... ...
Until the Part D prescription drug benefit goes into effect in 2006, beneficiaries can sign up for a federally approved drug discount card, with some low-income beneficiaries receiving a $600 subsidy to help pay drug costs, although relatively few have done so. As of January 2006, beneficiaries will be able to opt for private Part D insurance coverage.
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About 14 million beneficiaries with limited assets and annual incomes would have 85 to 95 percent of their prescription drug costs covered under Medicare (Kaiser Family Foundation, 2004b,f)
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The volunteer-based Road to Recovery program, for example, provides transportation for breast cancer patients to and from medical appointments and treatments (ACS, 2004b)
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The National Coalition for Cancer Survivorship, in collaboration with the Oncology Nursing Society, Association of Oncology Social Work, and National Association of Social Workers, has developed a Cancer Survival Toolbox that addresses health insurance and financial resources (NCCS, 2004)
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For the estimated 75,000 individuals facing bankruptcy as a result of cancer-related medical bills, a newly enacted bankruptcy law will make it more difficult for them to get out of debt. LIFE INSURANCE Obtaining life insurance coverage may be difficult for survivors of cancer.
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From page 416... ...
In addition, information and support can be provided to employees facing cancer through employer-sponsored health programs, workplace intranets, work-life programs, and employee assistance programs. Many employment-related services are available to cancer survivors through public and private voluntary and advocacy organizations, including education, counseling, support, legal advice, vocational rehabilitation, and referral.
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From page 417... ...
All Americans are at risk of becoming a cancer survivor and finding themselves without access to adequate and affordable health insurance. Cancer survivors, like other Americans with serious, chronic health conditions, face significant barriers to coverage because of their health status.
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From page 418... ...
These younger uninsured cancer survivors report problems in access to care due to concerns about cost -- 51 percent report delays in obtaining medical care; 44 percent report not getting needed care; and 31 percent report not getting needed prescription medicine. The financial problems posed by cancer loom larger, because even those with health insurance can have trouble paying for prescription drugs and other types of care.
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From page 419... ...
Consistent with this goal, the IOM Committee on Cancer Survivorship recommends the following steps that can be taken between now and 2010 to strengthen health security for cancer survivors. Recommendation 9: Federal and state policy makers should act to ensure that all cancer survivors have access to adequate and affordable health insurance.
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From page 420... ...
Policy makers could strengthen and build on this program first by ensuring that more eligible women with breast and cervical cancer are reached by it, and second by expanding screening services and Medicaid eligibility to include other cancer patients and survivors who have no other coverage options. All health insurance in the United States -- including Medicare, Medicaid, employer-sponsored group health plans, and individually purchased policies -- should cover effective cancer survivorship care.
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APPENDIX 6A DESCRIPTION OF THE NATIONAL HEALTH INTERVIEW SURVEY AND THE MEDICAL EXPENDITURE PANEL SURVEY AND THE METHODS USED TO DERIVE ESTIMATES OF INSURANCE COVERAGE AND MEDICAL EXPENDITURES PRESENTED IN THE CHAPTER NATIONAL HEALTH INTERVIEW SURVEY (NHIS) Information on the health insurance status of cancer survivors ages 25 to 64 is based on analyses of 4 years of NHIS data (2000 through 2003)
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From page 422... ...
. The uninsured are persons who did not report having health care coverage at the time of the interview under private health insurance (from employer or workplace, purchased directly, or through a state, local government, or community program)
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These expenditures are defined as the sum of direct payments for care provided during the year, including out-of-pocket payments and payments by private insurance, Medicaid, Medicare, and other sources. Payments for over-thecounter drugs, alternative care services, and phone contacts with medical providers are not included in MEPS total expenditure estimates.
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· Medicare -- A federally financed health insurance plan for the elderly, persons receiving Social Security disability payments, and most persons with end-stage renal disease. Medicare Part A, which provides hospital insurance, is automatically given to those who are eligible for Social Secu
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From page 425... ...
· Other sources -- Includes payments from Workers Compensation; other unclassified sources (automobile, homeowner's, or liability insurance, and other miscellaneous or unknown sources) ; and other private insurance (any type of private insurance payments reported for people without private health insurance coverage during the year as defined in MEPS)
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From page 426... ...
1993. The relation between health insurance coverage and clinical outcomes among women with breast cancer.
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From page 427... ...
2005. Health Insurance Coverage: Estimates from the National Health Interview Survey, 2004.
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From page 428... ...
2004. Income, Poverty, and Health Insurance Coverage in the United States: 2003.
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From page 429... ...
2003. Health insurance and cancer survival.
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2000. Current national health insurance coverage policies for breast and ovarian cancer prophylactic surgery.
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From page 431... ...
2003. Cancer survival in Kentucky and health insurance coverage.
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2001. The associa tion between socioeconomic status, health insurance coverage, and quality of life in men with prostate cancer.
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2003. Health insurance and spending among cancer patients.
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