Authors of a new paper published in JAMA Network Openassessed changes in the number of patients with new cancer diagnoses before and during the covid-19 pandemic. The primary outcome of interest was incidence in the new diagnosis of breast, colorectal, lung, pancreatic, gastric, and esophageal cancer by formal testing through Quest Diagnostics from 2019 to mid-April 2020. The data revealed that new diagnoses of cancers decreased significantly during covid-19 suggesting the possibility that a lack of testing and/or screening that would have normally occurred in offices that were closed during the first peak (and cancellations or reduced scheduling of outpatient procedures such as mammograms, colonoscopies, low-dose CT scans, etc.) resulted in delayed cancer screening. The authors report decreases in weekly diagnoses ranging from 16 percent (lung cancer) to 42 percent (breast cancer). 

We're not convinced this is as significant as it sounds. This paper was markedly limited in its analysis; it assessed only the weekly incidence of cancer diagnoses in the year preceding the pandemic. A stronger analysis would have included more than one year and compared seasons directly (e.g. spring 2020 versus spring of previous years). Second and somewhat surprisingly, the authors of the paper do not address whether a few months in the delay in diagnosing of these cancers would be expected to result in worse outcomes for the patients. This is because there is a difference in cancer diagnoses that are made because of symptoms (patients seeking medical attention for new and worrying symptoms) and those that are made via routine asymptomatic screening, such as colonoscopies, mammography, or prostate cancer PSA levels. Most people (including many physicians) are unaware of a growing body of literature showing that most routine asymptomatic cancer screening has not been proven to improve overall mortality in the general population (For more on this, check out some interesting papers on this topic here, here, and here). It turns out the screening detects cancer sooner but that these early diagnoses have not been shown to lengthen life. While this undermines the assumption that early detection is crucial to survival, the totality of the data are difficult to deny. For whatever reason, the assumption that early detection saves lives in truly symptom-free people just has not played out in the medical literature. It is therefore unlikely that delays in routine cancer screening in the outpatient setting during the covid-19 pandemic will go on to significantly change overall mortality at the population level. While some exceptions will of course occur, there are also many instances of "overtreatment" which may have been avoided because of these changes. An example of overtreatment is a prostate removal surgery in a patient with abnormal test results but which turns out to have not been cancerous. Some patients receive chemotherapy and radiation unnecessarily, which come with substantial health risks. One final methodologic problem to consider: the lead author of the paper is an employee of Quest Diagnostics, which should be viewed as an important financial conflict of interest. Why? Decreased testing during the pandemic means decreased revenue for Quest. From a certain perspective, it could be said after reading this paper that Quest Diagnostics has more to lose than patients with decreased routine cancer screening during the peak of the covid-19 pandemic. 

In a piece published today in the Journal of the American Medical Association, Larry Levitt of the Kaiser Family Foundation reflects on how the Affordable Care Act (ACA) has changed the health insurance landscape during the first economic downturn since its implementation. He notes that this "double whammy" of concurrent economic and public health crises would be even more devastating were it not for the ACA. In the United States, most of those insured by private health insurance plans qualify for that insurance through their employer and therefore are likely to lose their insurance when they lose their job. The covid-19 pandemic has resulted in record numbers of people filing for unemployment in the United States in the modern era. Through the ACA, those who do lose employment and insurance may qualify for subsidies from the federal government to buy an insurance plan on the marketplace or they may qualify for Medicaid, the government insurance program for individuals with low incomes. Medicaid expansion was one of the central tenets of the ACA, but has not been implemented in 14 states and thus is not available to all of those who are recently unemployed because of the novel coronavirus and resulting economic crisis. The change in the economic landscape is also likely to shrink state budgets which are often dominated by Medicaid spending, making the health insurance program a frequent target during budgetary belt tightening. 

Despite these ACA provisions, there are likely to be millions more people who are uninsured than there were at the beginning of the pandemic. To address this, there have been several proposals in Congress to help Americans remain insured despite job losses. Several Senators proposed a temporary extension of Medicare to those who are uninsured or underinsured and the House of Representatives passed a temporary subsidization of COBRA (Consolidated Omnibus Budget Reconciliation Act), a program which allows for continuation of health insurance from an employer despite no longer being their employee. However, neither of these proposals are likely to become law under the current political climate.

The Department of Health and Human Services (HHS) has announced extensions for Medicaid providers interested in applying for federal relief funds as part of the $15 billion allocation set aside in June. After many interested providers stated they found out about the program close to or after the July 20 deadline, HHS has extended the application cycle through August 28. Additionally, beginning the week of August 10, HHS is allowing Medicare providers to apply for a second round of funds from the $20 billion Medicare General Distribution who were unable to complete their forms under the initial timeline.

Finally, new owners of eligible Medicare programs will also be able to apply for funding that was previously denied under the original application rules as they applied to change in ownership. The Department of Health and Human Services