Policy and Payment Shifts on the Horizon: Navigating Uncertainty in Cancer Care
At a session CPC CBEx 2025 session, Amanda Berra, EVP, chief education officer at Union Health Care Insight, delivered a sobering yet actionable policy and payment landscape update that holds significant implications for oncology providers, payers, and the broader health care ecosystem. Moderated by Deirdre Saulet, PhD, chief innovation officer at Jasper Health, the session unpacked key policy changes embedded in the One Big Beautiful Bill Act (OBBA) legislation and explored cascading impacts across Medicaid, Medicare, commercial payers, and ultimately, patients.
Berra opened with a focus on Medicaid, spotlighting provisions in the OBBA legislation that will tighten eligibility, introduce work requirements, and reduce provider reimbursement via new caps on provider taxes. These changes are expected to reduce Medicaid enrollment over the next decade, threatening access for approximately 10 million Americans by 2034.
Saulet emphasized the consequences for oncology: “About 10% of adults with cancer who relied on Medicaid for their insurance in 2023.” She further noted, “Expanding access to Medicaid expands access to timely treatment for cancer…and has a big impact on people getting screened and adhering to recommended preventive care.”
Berra noted that while changes won’t take effect overnight, stakeholders should be aware of the timing: “The biggest bundle of eligibility checks and work requirements will not start to kick in until after the 2026 midterms.” The lag is strategic, she argued: “Congress’s effort to disconnect the action of passing the law from some of the consequences in 2026 is just common sense.”
Shifting to Medicare, Berra cautioned about sequestration risks that could mean “a 4% across-the-board cut for most Medicare services.” However, she tempered concern, citing congressional tools to bypass such cuts and the relative health of the Medicare Trust Fund.
Yet, Berra warned of a “wild card”: renewed interest in rebalancing physician payments, particularly increasing reimbursement for primary care at the expense of specialists. Berra cited early signals in the proposed physician payment schedule. In oncology, this equates to a 6% increase for hematology and oncology in community settings but an 11% decrease for hospital-based chemotherapy.
The session also dissected Medicare Advantage (MA), a program covering over 54% of eligible beneficiaries. While some anticipated the current administration would aggressively expand MA, Berra described their approach as “more hands-off than expected,” noting that even a 5% pay increase “wasn’t initiated—they just didn’t stop it.”
Nonetheless, significant policy constraints remain: “The administration has not stepped in to change anything the Biden administration put in place to curb low-value overspending in the Medicare Advantage program.” With many MA plans excluding access to NCI-designated cancer centers, the implications for oncology access and equity are profound.
In the commercial space, employer-sponsored insurance is grappling with unsustainable trends. Cost trend numbers are way up, about 9%, according to new Mercer data predicting the largest jump in per-employee health costs since 2010.
Cancer has now overtaken musculoskeletal conditions as the top cost concern for employers. Saulet underscored the opportunity: “They’re not super steeped in cancer care…it’s a real opportunity for folks in this room to think about strategy and how they work with regional employers.”
Employers are responding with familiar tools—narrow networks, centers of excellence, episodic payment—but also exploring newer models like virtual-first clinics and ICRAs (individual coverage HRAs), which Berra described as “basically a voucher program.”
The net result of these converging policy shifts is a slow return to pre-Affordable Care Act (ACA) levels of uninsurance. Berra warned, “If you add up these effects… you basically get a pre-ACA level of uninsurance.” Even those with insurance face rising exposure through higher deductibles and out-of-pocket maximums.
The implications for cancer care are stark. “Financial toxicity, cost exposure…have a real impact on mortality and survival rates,” Saulet emphasized. She urged providers to reinvest in financial counseling and rethink revenue cycle operations.
While the session leaned heavily on diagnosis over prescription, Berra and Saulet did leave attendees with tangible areas of focus including scenario planning and business model alignment to withstand Medicaid and MA shifts, investment in patient financial experience to buffer against rising cost exposure, partnerships with employers to manage the growing cancer burden in covered populations, and technology and analytics deployment to increase operational efficiency amid payment volatility.
Reference
Berra A, Saulet D. State of health care: what cancer stakeholders need to know. Presented at the Clinical Pathways Congress; September 5, 2024; Boston, MA.
