American Assoc. for Cancer Research - 2016 Annual Meeting

“The Impact of the Affordable Care Act

(ACA) on Cancer Research, Care, & Prevention”

April 17, 2016

Ernest Hawk, MD, MPH

Vice President & Head

Division of Cancer Prevention and Population Sciences

Duncan Family Institute

Ernest Hawk, MD, MPH Vice President & Head,

Division of Cancer Prevention and Population Sciences

Disclosure Information AACR 2016 Annual Meeting

Ernest Hawk, MD, MPH

I have the following financial relationships to disclose: Consultant for: Cancer Prevention Pharmaceuticals, PLx Pharma, Inc., Pozen, Inc. Grant/Research support from: NIH/NCI, CPRIT Honoraria from: Huntsman Cancer Institute, University of Kansas

Cancer Center, Mayo Clinic Cancer Center, Ohio State University Comprehensive Cancer Center, Roswell Park

Cancer Institute, University of Nebraska Medical Center, UT Southwestern Simmons Cancer Center Employee of: The University of Texas MD Anderson Cancer Center

- and - I will not discuss off label use and/or investigational use in my

presentation.

Premise for Prevention

One-Third to One-Half of Cancer Deaths are Preventable in Western Populations

Effective Cancer Prevention is Applied in Two Domains Across the Lifespan

Eliminate tobacco exposure

Eat a healthy diet

Be physically activity

Public policy

Education – public & professional

Delivery of community-based clinical services

Effective Cancer Prevention

Evidence-Based Personal Actions

Evidence-Based Population

Actions

Limit intense UV exposure

Follow a cancer-screening program

Use preventive meds & vaccines

Obesity/diet/inactivity

Colditz, et al. Sci Trans Med., 2012 AACR Cancer Progress Report, 2014

Know your family hx / risk assessment

Especially to Address the Unmet Needs of Those at

Greatest Risk

Prevention in the U.S. Affordable Care Act (ACA) Individuals

Section Name Summary

Coverage of Preventive Health Services New employer-sponsored plans & private ins. cover USPSTF rec’d preventive services without cost-sharing

Removal of Barriers to Preventive Services in Medicare

Eliminates copayments for Medicare preventive services that are rated A or B by USPSTF

Improving Access to Preventive Services for Eligible Adults in Medicaid

Federal medical assistance increased by 1% for preventive services in states that eliminate cost-sharing for rec’d services

Medicare Coverage of an Annual Wellness Visit Providing a Personalized Prevention Program

Eliminates copayments for Medicare enrollees who receive annual wellness exam that includes a HRA & personal prevention plan

Demonstration Project Concerning Individualized Wellness Plans

Pilot program to determine effectiveness of individualized wellness plans at FQHCs

Medicaid & Tobacco Pharmaceutical Coverage Prevents states from excluding coverage for tobacco cessation drugs in Medicaid programs

Coverage of Comprehensive Tobacco Cessation Services for Pregnant Women in Medicaid

Provides coverage without cost-sharing for tobacco dependence treatments for all pregnant women on Medicaid

Insurers’ coverage

Clinical Preventive Services Covered by the ACA

Prevention in the U.S. Affordable Care Act (ACA) Businesses & Workplaces

Section Name Summary

Reasonable Break Time for Nursing Mothers

Employers provide sufficient break time and appropriate facilities for nursing mothers

CDC & Employer-Based Wellness Plans CDC provides technical assistance to evaluate employer-based wellness programs & to conduct a survey of existing programs

Effectiveness of Federal Health & Wellness Initiatives

DHHS secretary evaluates effectiveness of existing federal health & wellness initiatives & reports to Congress

Grants for Small Businesses to Provide Comprehensive Workplace Wellness Grants

Grant program for small businesses to establish workplace wellness programs

Policies, technical assistance in evaluation, grants

Prevention in the U.S. Affordable Care Act (ACA) Communities & States

Section Name Summary

Incentives for Prevention of Chronic Diseases in Medicaid

State grants to provide Medicaid enrollees incentives to adopt & maintain healthy behaviors. (up to $100M beginning in FY2011)

Community Transformation Grants Competitive grants for state & local gov’t agencies & community-based organizations to implement, evaluate & disseminate EBPs to reduce rates of chronic conditions, improve prevention, reduce disparities, & decrease rates of disease

Grants to Promote the Community Health Workforce

Grants to improve health care in medically underserved areas through the use of community health workers

Grant incentives

Prevention in the U.S. Affordable Care Act (ACA) National

Section Name Summary

National Strategy to Improve Healthcare Quality

DHHS secretary establishes a national strategy to improve the delivery of health care services , patient health outcomes, & population health

National Prevention, Health Promotion, & Public Health Council

Council to provide coordination & leadership of prevention, wellness & health promotion practices at the federal level, & directs council to develop a national strategy on prevention

Prevention & Public Health Fund Expands & sustains national investment in prevention & public health programs via progressive annual budget increments reaching $2B/year

Clinical & Community Preventive Services

Promotes expanded coordination among the USPSTF, Community Preventive Services Task Force, & ACIP

Education & Outreach Campaign Regarding Preventive Benefits

Requires planning & implementation of a national public-private partnership for prevention & health promotion outreach education campaign to raise public awareness of health improvement across life span

Strategic planning, coordination, financial support

Prevention in the U.S. Affordable Care Act (ACA) National

Section Name Summary

Oral Healthcare Prevention Activities

Creates education, surveillance & research demonstration grants

Nutrition Labeling of Standard Menu Items at Chain Restaurants

Requires disclosure of specified nutritional information for food sold in certain chain restaurants & vending machines

Research on Optimizing Delivery of Public Health Services

Supports research in public health services & systems

Understanding Health Disparities: Data Collection & Analysis

Requires any federally conducted & supported public health programs to report appropriate data for analysis

National Healthcare Workforce Commission

Establishes a national commission to provide comprehensive information on workforce needs

Funding for National Health Service Corp

Expands & reauthorizes the National Health Service Corp

Young Women’s Breast Health Awareness & Support of Young Women with Breast Cancer

Authorizes a program to support awareness, knowledge, research, & support for breast cancer in young women

Research, support grants, policies

Prevention in the U.S. Affordable Care Act (ACA) National

Section Name Summary

National Diabetes Prevention Program

Authorizes a national program focused on reducing preventable diabetes in at-risk adult populations

Community Health Centers & the National Health Service Corp

Provides for expanded & sustained investment in community health centers. Appropriated up to $9.5B for Community Health Center Initiative between FY11 & FY15; up to $1.5B for National Health Service Corp between FY11 & FY15; up to $1.5B for construction & renovation of community health centers between FY11 & FY15.

Program implementation, implementation infrastructure

Implementation Timeline of Selected Prevention-Relevant Sections of ACA

2010

• Cost-free preventive services begin for insured Americans

• Coverage extended for young adults

• Funding begins from the PPHF

2011

• Free preventive services, wellness visit begin for seniors on Medicare

• Community transformation grants begin

2013

• Funding to state Medicaid programs to cover preventive services

• Open enrollment begins on Oct. 1st

2014

• Health Insurance Marketplace established

• Medicaid expanded to more low-income Americans

• Coverage of clinical trials

2016

• Menu-labeling required in chain restaurants (delayed by FDA until 2017)

Source: http://www.hhs.gov/healthcare/facts-and-features/key-features-pf-aca-by-year/index.html

Preventive Services Coverage under the ACA DHHS Estimates – 2013 & 2015

Source: DHHS ASPE Issue Brief. Seventy-One Million Additional Americans are Receiving Preventive Services Coverage without Cost-Sharing Under the ACA, March 2013. DHHS ASPE Data Point. The Affordable Care Act is Improving Access to Preventive Services for Millions of Americans. May 14, 2015.

2013 Estimate Of Additional Americans Receiving Preventive Services Coverage with No Cost-Sharing During

2011 & 2012

Children Women Men Total

18.3M 26.9M 25.7M 71M

2015 Estimate of Americans Who Have Preventive Services Coverage with No Cost-Sharing

Children Women Men Total

28.5M 55.6M 53.5M 137.7M

Impact of ACA’s Dependent Coverage Expansion (DCE) on Cervical Cancer Stage at Dx & Fertility-Sparing Treatment

• Objective: Cervix is only cancer site rec’d for screening in young adults

• Methods: Compared 21-25 y.o. to 26-34 y.o. pre & post ACA-DCE implementation using the Nat’l Cancer Database; 2010 considered phase-in period; Difference in Differences analysis performed

Ref: Robbins, et al. JAMA. v. 314(20); Nov 2015

Early-stage Cervical Cancer Fertility-Sparing Treatment

* *

Impact of ACA Provisions on HPV Vaccine Initiation & Completion

• Objective: To examine effect of ACA provisions for dependent coverage & preventive services on vaccine use among 19-25 y.o.

• Methods: Used 2008-2012 data from NHIS* on 10,010 women

Ref: Lipton & Decker. Health Affairs. v. 34(5); May 2015

Estimated Population Impact 1.1M additional women ages 19-25 initiated the vaccine

854,000 additional women ages 19-25 completed vaccine series

*NHIS, National Health Interview Survey

Impact of ACA Provisions on Screening for Breast & Colon Cancers

• Objective: To determine if ACA provisions increased screening likelihood or prevalence among Medicare & privately-insured adults

• Methods: Hamman, et al. used BRFSS data on 65,082 men & 98,409 women, 2008-2012; Fedewa, et al. used 2008 & 2013 Nat’l Health Interview Survey data on 15,786 adults for CRC analysis & 14,530 women for BC analysis

• Findings: Both found small-to-moderate significant increases in CRC screening post-ACA, particularly for those with lower incomes or less education; No changes noted for BC screening

Ref: Hamman & Kapinos. Health Affairs. v. 34(12); Dec 2015; Fedewa, et al. Cancer, Sept. 2015

Findings Hamman, et al., 2015 • Probability of colonoscopy w/in past year increased 4% for men (p < 0.01) • No changes in CRC screening for women • Screening rates increased 9.2% among men reporting cost as a barrier to medical

care (p < 0.05) and 7.5% among the least educated (p < 0.01)

Fedewa, et al., 2015 • Between 2008-2013, CRC screening prevalence increased from 57.3% to 61.2%

(p<0.001) • CRC screening prevalence increased the most in the least educated, 50.4% to

57.7% (p = 0.022) • No changes in breast cancer screening

• Only 3% of health care spending is focused on prevention & public health, although 75 % of health care costs are related to preventable conditions

• ACA addressed this by creating a mandatory fund

“to provide for expanded and sustained national investment in prevention and public health programs to improve health and help restrain the rate of growth in private and public health care costs.”

• Authorized $15 billion over 10 years, beginning in 2010

• Funds put to work through partnerships with states & communities

ACA’s Prevention & Public Health Fund

Source: American Public Health Association Fact Sheet: the Prevention and Public Health Fund. 2015. http://apha.org/topics-and-issues/health-reform/key-aca-resources

ACA’s Prevention & Public Health Fund

Does not include cuts due to sequestration

Source: American Public Health Association Fact Sheet: the Prevention and Public Health Fund. 2015. http://apha.org/topics-and-issues/health-reform/key-aca-resources

CDC’s ‘Tips from a Former Smoker’ Campaign Supported by ACA’s Prevention & Public Health Fund

• Objective: To evaluate the most recent round of CDC’s ‘Tips’ Advertising Campaign (July ‘14-Sept ‘14)

• Methods: Baseline and 4-month follow-up surveys of smokers (n=4,248) before vs. after the campaign (nationally representative longitudinal cohort)

Ref: Neff, et al. Prev Chronic Dis v. 13; March 2016

Findings Quit attempt rate ↑ 17%* post-campaign

Intentions to quit ↑ 28%* post-campaign

→ 1.83M quit attempts & 1.73M smokers intending to quit

Similar to results of 2012 campaign, with sustain impact over time

NOTES: Current status for each state is based on KCMU tracking and analysis of state executive activity. *AR, IA, IN, MI, MT, NH and PA have approved Section 1115 waivers. Coverage under the PA waiver went into effect 1/1/15, but it has transitioned coverage to a state plan amendment. Coverage under the MT waiver went into effect 1/1/2016. LA’s Governor Edwards signed an Executive Order to adopt the Medicaid expansion on 1/12/2016, but coverage under the expansion is not yet in effect. WI covers adults up to 100% FPL in Medicaid, but did not adopt the ACA expansion. See source for more information on the states listed as “adoption under discussion.” SOURCE: “Status of State Action on the Medicaid Expansion Decision,” KFF State Health Facts, updated March 14, 2016. http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/

Current Status of State Medicaid Expansion Decisions

WY

WI*

WV

WA

VA

VT

UT

TX

TN

SD

SC

RI

PA*

OR

OK

OH

ND

NC

NY

NM

NJ

NH*

NV NE

MT*

MO

MS

MN

MI*

MA

MD

ME

LA*

KY KS

IA*

IN* IL

ID

HI

GA

FL

DC

DE

CT

CO

CA

AR* AZ

AK

AL

Adopted (32 States including DC)

Not Adopting At This Time (19 States)

Impact of Medicaid Expansion Decisions on Receipt of Women’s Cancer Screenings

Ref: Sabik, et al. Am J Prev Med; v.48(1); 2015

• Objective: To determine potential impact of state Medicaid expansion decisions on disparities in rates of breast & cervical screening

• Methods: Used 2012 BRFSS screening data & 2014 CMS data re: state Medicaid expansion decisions; • Mammogram sample=56,484 • Pap test sample=84,867

Expansion States

Non-expansion States

Findings Women in non-expansion states had significantly lower odds of

receiving mammograms (OR=0.87; 95% CI:0.79-0.95) or pap tests (OR=0.87; 95% CI: 0.79-0.95)

This difference was larger among uninsured:

Odds of Mammogram=0.72 (95% CI: 0.56-091) Odds of Pap Test=0.78 (95% CI: 0.65-0.94)

Disparities in screening by race and income are likely to widen

Impact of ACA on the Philosophy of U.S. Health Care

• Elevates prevention as a national priority

• Provides improved access to clinical preventive services

• Promotes workplace wellness

• Strengthens the vital role of communities in promoting prevention

• Authorizes heavy investments to bolster the primary care workforce

• Prioritizes the 2 major risk factors for cancer and numerous chronic diseases in the American population - tobacco & obesity

“Moving prevention toward the mainstream of health may well be one of the most lasting legacies of this landmark legislation.”

Koh & Sebelius, NEJM 2010 Source: Koh & Sebelius, NEJM v.363(14);2010.

“The function of protecting and developing health must rank even above that of restoring it when it is impaired.” Hippocrates