The Affordable Care Act and Two-Tiered Cancer Care: Is This a Bad Thing?

Craig Deligdish, MD

May 2014, Vol 5, No 4 - From the Editor

Defining and improving quality and outcomes in the care of patients with cancer is difficult, so it is interesting that we are now having a dialogue regarding the potential for a two-tiered healthcare system. Can we really define second-class cancer care if we have difficulty grading, measuring, identifying, or even defining first-class cancer care?

The Affordable Care Act (ACA) has mandated coverage to many people who previously did not have coverage provided by their employer or by the federal government, who did not want to purchase insurance coverage, or who could not afford it. Now, as a result of Medicaid expansion and enrollment in the exchanges, millions of Americans who previously did not have health insurance are getting it either at no cost or at a lower cost than what they would have paid on their own.

The medical and the lay communities are challenged with differentiating and measuring quality and outcomes from one provider to another and from one hospital system to another. Therefore, we are frequently left with cost as the defining factor in the determination of value. Recently, much has been written about the development of a two-tiered Canadian-style healthcare system.

In his May 23, 2013, article in Forbes, “Coming Soon To America: A Two-Tiered, Canadian-Style Health Care System” (, John Goodman discusses the evolution toward a two-tiered system, which was under way before President Obama came into office. He points out that the ACA has accelerated this process by creating a system that will require a number of essential benefits. The concern from Goodman’s perspective is that there will not be a sufficient amount of physicians to care for the patients covered by the ACA.

Limited resources will result in a system similar to the Canadian system, in which patients with one form of insurance have access to care, and those with another form of insurance have less access. The fact that some of the benefits provided to patients covered by the exchanges may be only partially covered with a 40% coinsurance is emblematic of this concern.

But then, is a two-tiered healthcare system problematic? The goal of the ACA is, in part, to ensure coverage for all Americans. Coverage does not mean premium healthcare, and it does not mean that all Americans will have the same coverage at the same cost. The ACA was partially designed to provide patients who previously did not have health insurance with essential benefits. Before the ACA, patients generally had access to treatment for cancer, whether it was based on the provision of community health providers, contributions from pharmaceutical companies, or community and public hospital systems. Today, access to these systems has been narrowed, and many commercial insurance providers, as well as health exchanges, have constricted networks that limit access to some providers. This has resulted in some degree of outrage.

However, is there anything wrong with a two-tiered system? The European and Australian systems of healthcare, as well as healthcare in many Westernized countries whose governments provide healthcare to all citizens, have generally resulted in the two-tier system. Is that better than no healthcare at all?

The philosophy in the United States has always been to provide access to everything. In the United States, consumers make a choice based on cost, value, and quality. Should healthcare be any different? When someone goes to the supermarket, that person chooses between the store brand and the premium brand. Should healthcare be any different? Has the US government changed that philosophy, or is healthcare so different from everything else that is purchased and consumed?

Consumers of healthcare in the United States will find themselves needing to make more choices, yet at times they may find that their choices are limited, and that there may not be sufficient transparency for them to make their choices.

Patients and consumers will need to choose between a narrow network and a wide network, a health plan with essential benefits and a plan with a comprehensive benefit plan, generic versus brand, and centers of excellence versus centers of value. Health plans and consumers will need to make choices considering the cost and the limited resources that are available to them.

This will be the new paradigm, and at the end of the day, we will need to ask whether we are better off.