Effects of Insurance Expansions on Cancer Treatment: Recent Policy Changes and Implications for Future Reform

项目摘要/摘要 在美国，癌症是最常见的死亡原因之一，也是最昂贵的疾病之一，而且及时获得 高质量的治疗对于将癌症发病率和死亡率降至最低至关重要。保险承保范围是 影响获得护理机会的重要决定因素，这也是造成记录在案的结果差异的原因。这个 《平价医疗法案》(ACA)通过补贴扩大了非老年人获得保险的机会 覆盖市场，并将医疗补助扩大到参与州的低收入成年人。几乎没有什么 关于保险覆盖面扩大对癌症护理机会或质量的影响的证据。这个 拟议的项目将利用ACA条款的时间变化和这些条款下的覆盖范围的变化 评估保险覆盖范围扩大对癌症的影响的跨地理地区的拨备 治疗。我们使用了宾夕法尼亚州的基于人口的数据，宾夕法尼亚州是医疗补助计划扩大规模最大的州 在ACA之前，没有广泛覆盖低收入成年人。数据来自宾夕法尼亚州- 广泛的癌症登记，以及来自All-Pay住院患者、医院门诊患者和门诊手术的数据 宾夕法尼亚州医疗保健成本控制委员会(PHC4)的中心管理文件，链接到 在个人一级进行登记。样本包括该州所有非老年成年癌症患者， 所有付款人的出院信息，包括未参保患者的信息。我们使用一种准实验式 评估私人(市场)和公共(医疗补助)扩展对获得医疗服务的影响的方法 以及对被诊断为四种最常见癌症(乳腺癌、前列腺癌、肺癌和 结直肠)。具体地说，我们考察了保险扩张对癌症保险覆盖面的影响。 患者(目标1)、获得癌症治疗的机会(目标2)和癌症护理质量(目标3)。我们假设 覆盖面的增加将与从诊断到治疗的更短时间相关；更高的可能性 在经认证的癌症中心、学术中心和高容量医院进行治疗；增加了 指导方针一致的护理；减少住院再入院。所有的分析都将按癌症类型进行分层， 允许评估不同癌症的不同影响，我们将评估保险的作用 在缩小种族/族裔少数群体和农村人口获得机会方面的差距方面的覆盖面。该项目将 提供详细证据，说明ACA如何影响癌症的保险覆盖范围、获取途径和护理质量 患者，包括对服务不足的种族/族裔少数群体和农村地区现有护理差距的影响 病人。详细了解医疗保险覆盖面扩大对癌症护理的影响 (美国最昂贵和最致命的疾病之一)将告知正在辩论的联邦和州政策制定者 医疗改革提案，项目官员寻找证据指导发展和实施 覆盖范围和护理提供政策，以及研究人员评估持续的政策变化和干预措施，以 减少癌症护理方面的差距。

PROJECT SUMMARY/ABSTRACT Cancer is among the most common causes of death and most costly diseases in the US, and timely access to high quality treatment is essential for minimizing cancer morbidity and mortality. Insurance coverage is an important determinant of access to care that contributes to documented disparities in outcomes. The Affordable Care Act (ACA) expanded access to insurance for non-elderly adults through subsidized Marketplace coverage and expansion of Medicaid to low-income adults in participating states. There is little evidence regarding the impact of insurance coverage expansions on access to or quality of cancer care. The proposed project will leverage variation in the timing of ACA provisions and changes in coverage under those provisions across geographic areas to estimate the impacts of insurance coverage expansions on cancer treatment. We use population-based data from Pennsylvania – the largest Medicaid expansion state that did not have extensive coverage for low-income adults prior to the ACA. Data come from the Pennsylvania state- wide cancer registry, along with data from all-payer inpatient, hospital outpatient, and ambulatory surgery center administrative files from the Pennsylvania Health Care Cost Containment Council (PHC4), linked to the registry at the individual level. The sample includes all non-elderly adult cancer patients in the state, with discharge information across all payers, including for uninsured patients. We use a quasi-experimental approach to estimate the effects of both private (Marketplace) and public (Medicaid) expansions on access to and quality of care for patients diagnosed with the four most common cancers (breast, prostate, lung and colorectal). Specifically, we examine the impact of insurance expansions on insurance coverage for cancer patients (Aim 1), access to cancer treatment (Aim 2), and quality of cancer care (Aim 3). We hypothesize that increases in coverage will be associated with shorter time from diagnosis to treatment; higher likelihood of treatment in accredited cancer centers, academic centers, and high-volume hospitals; increased receipt of guideline concordant care; and reductions in hospital readmission. All analysis will be stratified by cancer type, allowing for assessment of differential impacts across cancers, and we will assess the role of insurance coverage in reducing disparities in access for racial/ethnic minorities and rural populations. The project will provide detailed evidence on how the ACA affected insurance coverage, access, and quality of care for cancer patients, including the impact on existing disparities in care for underserved racial/ethnic minority and rural patients. A detailed understanding of the impacts of health insurance coverage expansions on care for cancer (among the most costly and deadly diseases in the US) will inform federal and state policymakers debating health reform proposals, program officials seeking evidence to guide development and implementation of coverage and care delivery policies, and researchers assessing ongoing policy changes and interventions to reduce disparities in cancer care.