Understanding the impact of the Affordable Care Act on healthcare coverage, utilization, and outcomes for childhood cancer survivors

项目摘要/摘要 儿童癌症幸存者与晚期癌症相关的慢性病和死亡率增加 癌症治疗的效果，特别是在他们成年后。而终生后续护理，特别是 监测危及生命的后遗症至关重要，许多儿童癌症幸存者从未接受过 随访。缺乏医疗保险覆盖范围是获得所需医疗服务的关键障碍 儿童癌症的成年幸存者，低收入成年幸存者特别容易患上 未投保或保险不足。《平价医疗法案》(ACA)为各州提供了扩大医疗补助的选择 从2014年开始覆盖所有收入≤为联邦贫困水平138%的成年人。到目前为止，还没有研究表明 审查了ACA医疗补助扩大对扩大保险覆盖面的影响，改善了获得 推荐的生存护理，或儿童晚期死亡率的相关下游变化 癌症幸存者。我们将研究大约20,000名儿童癌症成年幸存者的队列 儿童癌症幸存者研究(CCSS)在1970年期间被诊断为21岁或以下的癌症患者- 1999年，以及他们的4,000名兄弟姐妹，在美国各州和华盛顿特区。全国CCSS队列将允许 确定ACA医疗补助扩大对医疗补助净影响的严格准实验方法 覆盖范围、卫生服务利用率和晚期死亡率。CCSS队列将与国家 行政医疗补助数据文件，横跨前四年(2010-2013)和后四年(2014-2017) 实施医疗补助扩围，跟踪医疗补助参保率和医疗补助覆盖面的稳定性。 数据链接还将允许全面捕获主要驱动因素的筛查服务利用率 晚期死亡率，反映获得符合生存指南的医疗保健的机会有所改善，以及使用 急诊科(ED)和住院服务，这是获得非急诊科门诊护理的有限机会的标志。 所有CCSS参与者与国家死亡指数的现有联系将使我们能够追踪死亡率和死因 截至2017年12月31日，该人口的死亡人数。这项研究将为癌症的政策干预提供信息 控制以减少儿童癌症幸存者的后遗症相关发病率和死亡率。

PROJECT SUMMARY/ABSTRACT Childhood cancer survivors have increased risks for chronic conditions and mortality associated with late effects of cancer treatment, particularly in their adult years. While lifetime follow-up care, specifically surveillance for life-threatening late effects, is vitally important, many childhood cancer survivors never receive follow-up care. Lack of health insurance coverage is a key barrier to accessing needed healthcare services for adult-aged survivors of childhood cancer, with low-income adult survivors particularly vulnerable to being uninsured or underinsurance. The Affordable Care Act (ACA) provided an option for states to expand Medicaid coverage starting in 2014 to all adults with income ≤138% of the federal poverty level. To date, no studies have examined the impact of the ACA Medicaid expansion on increasing insurance coverage, improving access to recommended survivorship care, or the associated downstream changes in late mortality among childhood cancer survivors. We will study a cohort of approximately 20,000 adult survivors of childhood cancer from the Childhood Cancer Survivor Study (CCSS) who were diagnosed with cancer at age 21 or younger during 1970- 1999, as well as 4,000 of their siblings, across all US states and D.C. The nationwide CCSS cohort will allow a rigorous quasi-experimental approach to determine the net effect of the ACA Medicaid expansion on Medicaid coverage, health service utilization, and late mortality. The CCSS cohort will be linked to the national administrative Medicaid data files, spanning four years before (2010-2013) and after (2014-2017) the implementation of Medicaid expansion, to trace Medicaid participation rates and stability of Medicaid coverage. The data linkage will also allow the comprehensive capture of utilization of screening services for key drivers of late mortality, reflecting improved access to healthcare concordant with survivorship guidelines, as well as use of emergency department (ED) and inpatient services, a marker for limited access to non-ED ambulatory care. The existing link of all CCSS participants to the National Death Index will allow us to trace mortality and cause of death in this population through December 31, 2017. This research will inform policy interventions for cancer control toward reducing late effects related morbidity and mortality for childhood cancer survivors.