Changes in Insurance Coverage and Stage at Diagnosis Among Nonelderly Patients With Cancer After the Affordable Care Act
Changes in Insurance Coverage and Stage at Diagnosis Among Nonelderly Patients With Cancer After the Affordable Care Act
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DOI：
10.1200/jco.2017.73.7817
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发表时间：
2017-12-10
影响因子：
45.3
通讯作者：
Han, Xuesong
中科院分区：
文献类型：
--
作者：
Jemal, Ahmedin;Lin, Chun Chieh;Han, Xuesong
目的检测《平价医疗法案》实施后，非老年新诊断癌症患者未参保比例和早期诊断比例的变化。患者与方法利用国家癌症数据库，按家庭收入水平估算2011年至2013年第三季度(实施《平价医疗法案》前)和2014年第二至第四季度(实施《平价医疗法案》后)18岁至年龄段新诊断癌症患者未参保比例的绝对变化和相对变化。我们还检查了人口统计学因素调整后的医疗补助扩展和非扩展状态之间的APC差异。结果在ACA前和ACA后期间，在医疗补助扩展和非扩展状态下，在所有收入类别中，新诊断癌症患者中未参保的百分比都有所下降。然而，居住在扩张状态的低收入患者的降幅最大(9.6%至3.6%；APC，-6.0%；95%CI，-6.5%至-5.5%)与居住在非扩张状态的患者(14.7%至13.3%；APC，-1.4%；95%CI，-2.0%至-0.7%)相比，调整后的差异为-3.3(95%CI，-4.0至-2.5)。按癌症类型划分，未参保比例下降最大的是与吸烟或感染相关的癌症患者。在居住在扩展状态的患者中，发现早期诊断结直肠癌、肺癌、女性乳腺癌、女性乳腺癌和黑色素瘤的比例很小，但有统计学意义。结论在ACA之后，非老年新诊断癌症患者的未参保比例大幅下降，特别是在居住在医疗补助扩展状态的低收入人群中。还发现了对处于扩张状态的选定癌症进行早期诊断的趋势。这些结果加强了旨在为低收入、弱势人口提供负担得起的保险的政策的重要性。
PurposeTo examine change in the percent uninsured and early-stage diagnosis among nonelderly patients with newly diagnosed cancer after the Affordable Care Act (ACA).Patients and MethodsBy using the National Cancer Data Base, we estimated absolute change (APC) and relative change in percent uninsured among patients with newly diagnosed cancer age 18 to 64 years between 2011 to the third quarter of 2013 (pre-ACA implementation) and the second to fourth quarter of 2014 (post-ACA) in Medicaid expansion and nonexpansion states by family income level. We also examined demographics-adjusted difference in differences in APC between Medicaid expansion and nonexpansion states. We similarly examined changes in insurance and early-stage diagnosis for the 15 leading cancers in men and women (top 17 cancers total).ResultsBetween the pre-ACA and post-ACA periods, percent uninsured among patients with newly diagnosed cancer decreased in all income categories in both Medicaid expansion and nonexpansion states. However, the decrease was largest in low-income patients who resided in expansion states (9.6% to 3.6%; APC, -6.0%; 95% CI, -6.5% to -5.5%) versus their counterparts who resided in nonexpansion states (14.7% to 13.3%; APC, -1.4%; 95% CI, -2.0% to -0.7%), with an adjusted difference in differences of -3.3 (95% CI, -4.0 to -2.5). By cancer type, the largest decrease in percent uninsured occurred in patients with smoking- or infection-related cancers. A small but statistically significant shift was found toward early-stage diagnosis for colorectal, lung, female breast, and pancreatic cancer and melanoma in patients who resided in expansion states.ConclusionPercent uninsured among nonelderly patients with newly diagnosed cancer declined substantially after the ACA, especially among low-income people who resided in Medicaid expansion states. A trend toward early-stage diagnosis for select cancers in expansion states also was found. These results reinforce the importance of policies directed at providing affordable coverage to low-income, vulnerable populations.