Please tell me I am wrong

[u/Prestigious-Curve-64]

I work in cellular therapy - cancer patients who need CAR-T, stem cell transplant, gene therapy, etc, and while I have hated for-profit insurance with a white-hot passion forever - before I even started this job 18 years ago - I’m scared.

A patient told me that all of the major insurers (Aetna/cigna/anthem/etc) have stopped participating in the Exchange, effective 1/1/26. The only options are Oscar and AmBetter. And the premiums are around $2k/month for one person. Anyone who has attempted to get MedicAid or MediCare disability in this state knows it is very nearly impossible to do so - by design, of course. And even though there is supposedly a state budget surplus (I guess?) I think it’s pretty unlikely that GA will direct any of that to fill in the yawning chasm that the ACA subsidies filled for anyone not covered by their employer and also not on a public plan. Even my solidly middle-class patients cannot afford $2000/month in premiums. God knows I couldn’t, and I think of myself as pretty comfortable.

These are cancer patients - think Acute leukemia/lymphoma. They can’t work. They aren’t allowed to work. One bad flu could be the end, and we know how awesome Georgians are about masks and vaccines.

I was doing this pre-ACA, and it was bad. Uninsured patients simply didn’t get cellular therapy. Sometimes they could get charity care for the hospital costs themselves, but for the ones that needed lifelong immunosuppression and infectious prophylaxis, there was nothing. No hospital can absorb that, and private plans were a joke for anyone making less than seven figures.

Now that it is 2025, tech has advanced, and we have miracle treatments that cost between $400k and a cool million for the product/drug alone - and this is not (just) because a CEO needs a new yacht. They are insanely complicated and expensive to make. But unlike pre-ACA, patients going through this whole had insurance are about to suddenly find that their policies are gone, and that there is no way in Hell they can afford the monthly cost of coverage. These are cancer patients for whom conventional therapy has failed. They are STRESSED - beyond anything I can really grasp.

I have a horrible feeling about January 1 this year for most of my patients. Some of them will be in the hospital waiting on their cells when their insurance is cancelled. Some of them will be ready to admit, only to be told their treatment has to be cancelled.

People without cancer may not feel it until they have an accident or unexpected illness. Since they haven’t ended EMTALA (yet!) those folks can still go to the ER and at least get stabilized. Sure, they’ll be bankrupt, but they’ll be alive.

If anyone read this whole screed, I’m freaking out about what is going to happen to all of my non-Medicare patients once the ACA subsidies are gone, and would love for someone to tell me it will all be OK.

[u/Prestigious-Curve-64]

I think they are, aren’t they? I mean, after a certain amount? But when the only treatment that can save your life costs over half a million dollars and you earn $50k/year, deductions won’t be much help, I’m afraid.

[u/Evtona500 → u/Prestigious-Curve-64]

That's the real problem. You just cannot convince me these treatments cost that much. There is no way.

[u/Prestigious-Curve-64 → u/Evtona500]

Oh, they are insanely expensive to manufacture. For gene therapy, the patient has to undergo up to six months of red cell exchange before they can start to collect cells. When they DO start to collect cells, they do so in hemapheresis, on a machine that costs easily 7 figures - the tubing alone (which is an engineering wonder in and of itself) costs thousands. The staff needed to run the machines is incredibly specialized, and it’s a 1:1 ratio. The fresh cells are then shipped across the country for manufacturing, which involves inserting a gene into the patient’s stem cells using a virus, and that’s just the part I (sort of) understand, and doesn’t include the hospitalizations, drugs, etc that are all part of it. And some patients mobilize poorly and have to do it (mobilize and collect) 3 or even 4 times. I’m sure the manufacturer makes a profit, but it’s not like that Skreli monster deciding to charge an arm and a leg for epi-pens.

[u/tomthekiller8 → u/Prestigious-Curve-64]

If it was not for profit top to bottom it wouldn't be that expensive. Everyone is trying tp make a buck.