community factors, can also drive these disparities (see discussion in Chapter 2).

At the same time, the increased costs of cancer care are negatively impacting patients and their families (Bernard et al., 2011; Shankaran et al., 2012). People with cancer are at higher risk for bankruptcy than people without a cancer diagnosis (Ramsey et al., 2013). In addition, a survey found that more than a third of individuals reported that medical problems were the reason for bankruptcy, even though three out of four families studied had insurance at the onset of illness (Himmelstein et al., 2009). From a system perspective, health care costs, including the costs of cancer care, are on an unsustainable trajectory that could pose serious fiscal consequences for the United States. Drivers of increased cancer spending include the aging population and the associated increase in cancer diagnoses, as well as the diffusion of new innovations into practice that may or may not be supported by evidence of better patient outcomes. In addition, the current fee-for-service reimbursement system encourages a high volume of care, but fails to reward the provision of high-quality care.

This chapter presents the committee’s vision for an accessible and affordable high-quality cancer care delivery system. The first half of the chapter discusses access to care, including the importance of health insurance coverage and barriers to care for vulnerable and underserved populations. The second half of the chapter addresses the affordability of cancer care, reviewing the current challenges to delivering affordable cancer care and strategies for improvement, including eliminating waste, encouraging high-quality cancer care through new payment models, and considering changes to benefit design. The committee derived much of the evidence base on access from the IOM’s previous work in this area (IOM, 1993, 2001, 2003, 2004, 2009a). Presentations and discussions from the National Cancer Policy Forum workshop Delivering Affordable Cancer Care in the 21st Century informed the committee’s deliberations on affordability (IOM, 2013a). The committee identifies two recommendations to address the pressing problems of access and affordability.


Access to care, or “the timely use of personal health services to achieve the best possible health outcomes” (IOM, 1993, p. 4), is an important aspect of high-quality cancer care (IOM and NRC, 1999). Patients’ health insurance status is a factor influencing an individual’s ability to access high-quality cancer care. Certain health system, patient, and clinician characteristics can also affect patients’ access to care and cancer care outcomes. This section discusses the impact of health insurance coverage on

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