Early impact of the Patient Protection and Affordable Care Act on insurance among young adults with cancer: Analysis of the dependent insurance provision

Age-related differences in employment, insurance, and financial hardship among colorectal cancer patients: a report from the ColoCare Study

PURPOSE

Employment and financial hardships are common issues for working-age colorectal cancer patients. We surveyed colorectal cancer survivors to investigate employment, insurance, and financial outcomes by age at diagnosis.

METHODS

Cross-sectional survey of six ColoCare Study sites regarding employment, insurance, and financial hardship outcomes. Eligible participants were 1 to 5 years from colorectal cancer diagnosis. Diagnosis age (18-49, 50-64, 65+ years) with outcomes of interest were compared using chi-square and t-tests. Multivariable logistic and Poisson regressions were fit to examine association of demographic factors with any material/psychological hardship (yes/no) and the count of hardships.

RESULTS

N = 202 participants completed the survey (age: 18-49 (n = 42, 20.8%), 50-64 (n = 79, 39.1%), 65+ (n = 81, 40.1%)). Most diagnosed age < 65 worked at diagnosis (18-49: 83%; 50-64: 64%; 65+ : 14%, p < 0.001) and continued working after diagnosis (18-49: 76%; 50-64: 59%; 65+ : 13%; p < 0.001). Participants age 18-49 reported cancer-related difficulties with mental (81.3%) and physical (89%) tasks at work more than those working in the older age groups (45%-61%). In regression models, among those reporting any hardship, the rates of material and psychological hardships were higher among those age 18-64 (Incidence Rate Ratios (IRR) range 1.5-2.3 vs. age 65+) and for those with < college (IRR range 1.3-1.6 vs. college +).

CONCLUSIONS

Younger colorectal cancer patients are more likely to work after a cancer diagnosis and during cancer treatment, but report higher levels of financial hardship than older patients.

IMPLICATIONS FOR CANCER SURVIVORS

Younger colorectal cancer patients may encounter financial hardship, thus may feel a need to work during and after treatment.

Future of Treatment of Adolescents and Young Adults With ALL: A Vision for Collaboration and Equity

Over the past several decades, survival of children with ALL has improved dramatically with treatment regimens refined through cooperative group trials. Despite aggressive treatment and iterative therapy changes for adolescents and young adults (AYAs), improvement has not been as promising. Comparisons between pediatric and adult clinical trials have consistently demonstrated superior outcomes for AYAs treated on pediatric ALL protocols, leading to the implementation of pediatric-inspired ALL protocols by several groups worldwide and/or expansion of the age limit of pediatric trials to include the full spectrum of the AYA population. Despite these efforts, AYAs in both pediatric and adult settings continue to have inferior survival compared with younger children with ALL. Real-world data suggest that uptake of pediatric-style treatment is variable, and even with identical pediatric-style treatment, AYAs still fare worse than younger children. As we enter an era of immunotherapy and precision medicine for newly diagnosed ALL, now is an opportune time to consider how best to approach future therapy for AYA patients. Comparisons of pediatric and adult treatment approaches and subanalyses of AYA patients will help guide harmonization of treatment. The focus of the next stage of ALL therapy for AYA should not only involve novel treatment approaches but also standardization and optimization of supportive care measures, psychosocial support, adherence interventions, oncofertility treatment, and survivorship care. All these efforts should simultaneously work to address health disparities to ensure that a future of improved outcomes is experienced equitably for all AYA patients.

Survival Trends Among Adolescents and Young Adults Diagnosed With Cancer in the United States: Comparisons With Children and Older Adults

PURPOSE

Although data from 1975 to 1997 revealed a gap in cancer survival improvement in adolescents and young adults (AYAs; 15-39 years) compared with children and older adults, more recent studies have reported improvements in AYA cancer survival overall. The current analysis provides an update of 5-year relative survival and cancer survival trends among AYAs compared with children and older adults.

METHODS

We obtained data from the National Cancer Institute Surveillance, Epidemiology, and End Results Program for 17 regions to obtain recent (2010-2018) 5-year relative survival estimates by cancer type, stage, sex, and race/ethnicity by age group. In addition, we calculated 5-year relative survival trends during 2000-2014.

RESULTS

Across 33 common AYA cancers, AYAs and children had high 5-year relative survival (86%) and experienced similar survival improvements over time (average absolute change: AYAs, 0.33%; children 0.36%). Among AYAs, 73% of cancers had improvement in 5-year relative survival since 2000. Despite this overall progress, we identified cancers where survival was worse in AYAs than younger or older patients and cancers that have had either a lack of improvement (osteosarcoma and male breast) or decreases in survival (cervical and female bladder) over time. Furthermore, males had inferior survival to females for all cancers, except Kaposi sarcoma and bladder cancer, and non-Hispanic Black/African American AYAs experienced worse survival than other racial/ethnic groups for many cancers considered in this study.

CONCLUSION

Future studies should focus on identifying factors affecting survival disparities by age, sex, and race/ethnicity. Differences in biology, clinical trial enrollment, delivery of treatment according to clinical guidelines, and supportive and long-term survivorship care may account for the survival disparities we observed and warrant further investigation.

Health Care Access Barriers and Self-Reported Health Among Adolescent and Young Adult Cancer Survivors

Purpose: Adolescents and young adult (AYA) cancer survivors (15-39 years at diagnosis) are at risk for treatment-related late effects but face barriers in accessing survivorship care. We examined the prevalence of five health care access (HCA) barriers: affordability, accessibility, availability, accommodation, and acceptability. Methods: We identified AYA survivors from the University of North Carolina (UNC) Cancer Survivorship Cohort who completed a baseline questionnaire in 2010-2016. Participants had a history of cancer, were ≥18 years of age, and receiving care at a UNC oncology clinic. The sample was restricted to AYA survivors who were interviewed ≥1 year postdiagnosis. We used modified Poisson regression to estimate prevalence ratios (PRs) for the association between HCA barriers and self-reported fair or poor health, adjusted for sociodemographic and cancer characteristics. Results: The sample included 146 AYA survivors who were a median age of 39 at the time of the survey. The majority (71%)-and 92% of non-Hispanic Black survivors-reported at least one HCA barrier, including acceptability (40%), accommodation (38%), or affordability (31%). More than one-quarter of survivors (28%) reported fair or poor health. Affordability barriers (PR: 1.89, 95% confidence interval [CI]: 1.13-3.18) and acceptability barriers (PR: 1.60, 95% CI: 0.96-2.66) were associated with a higher prevalence of fair/poor health, as were the cumulative effects of multiple HCA dimensions reported as barriers. Conclusions: Barriers across multiple HCA dimensions were prevalent and associated with worse health in AYA survivors. Findings highlight the need to better understand and target specific barriers to care for diverse AYA survivors to improve their long-term health.

Health insurance coverage among incident cancer cases from population-based cancer registries in 49 US states, 2010-2019

Having health insurance coverage is a strong determinant of cancer care access and survival in the United States. The expansion of Medicaid income eligibility under the Affordable Care Act has increased insurance coverage for working-age adults. Using data from the Cancer Incidence in North America (CiNA) in 2010-2019, we identified 6 432 117 incident cancer cases with known insurance status diagnosed at age 18-64 years from population-based registries of 49 states. Considerable variation in Medicaid coverage and uninsured rate exists across states, especially by Medicaid expansion status. Among expansion states, Medicaid coverage increased from 14.1% in 2010 to 19.9% in 2019, while the Medicaid coverage rate remained lower (range = 11.7% - 12.7%) in non-expansion states. The uninsured rate decreased from 4.9% to 2.1% in expansion states, while in non-expansion states, the uninsured rate decreased slightly from 9.5% to 8.1%. In 2019, 111 393 cancer cases (16.9%) had Medicaid coverage at diagnosis (range = 7.6%-37.9% across states), and 48 357 (4.4%) were uninsured (range = 0.5%-13.2%). These estimates suggest that many patients with cancer may face challenges with care access and continuity, especially following the unwinding of COVID-19 pandemic protections for Medicaid coverage. State cancer prevention and control efforts are needed to mitigate cancer care disparities among vulnerable populations.

Factors contributing to financial distress in young adults with cancer: Material resources, health, and workplace

BACKGROUND

Financial distress is a primary concern for young adults with cancer.

OBJECTIVE

The aim of this study was to identify material resources, physical and psychological health, and workplace variables that are associated with financial distress in young adult cancer survivors.

METHODS

A cross-sectional study was conducted using the Cancer Survivor Employment Needs Survey. Participants were young adults (18-39 years of age) who lived in the United States and had a cancer diagnosis. Multivariable linear regression was used to model relations between financial distress and material resources, physical and psychological health, and workplace variables.

RESULTS

Participants (N = 214) were mostly non-Hispanic White (78%), female (79%), and had a mean age of 31 years and 4.6 years post-diagnosis. Material resources, physical and psychological health, and workplace variables were all identified as contributing to study participants' financial distress. Among the young adults surveyed, financial distress was prevalent, and an array of problems were associated with financial distress.

CONCLUSION

Oncology and rehabilitation providers should openly discuss finances with YAs with cancer and guide them to resources that can address their financial, benefits, and vocational needs to ultimately improve quality of life.

The long-term financial experiences of adolescent and young adult cancer survivors

BACKGROUND

Cancer-related financial hardship can negatively impact financial well-being and may prevent adolescent and young adult (AYA) cancer survivors (ages 15-39) from gaining financial independence. This analysis explored the financial experiences following diagnosis with cancer among AYA survivors.

METHODS

We conducted a cross-sectional, anonymous survey of a national sample of AYAs recruited online. The Comprehensive Score for Financial Toxicity (COST) and InCharge Financial Distress/Financial Well-Being Scale (IFDFW) assessed financial hardship (cancer-related and general, respectively), and respondents reported related financial consequences and financial coping behaviors (both medical and non-medical).

RESULTS

Two hundred sixty-seven AYA survivors completed the survey (mean 8.3 years from diagnosis). Financial hardship was high: mean COST score was 13.7 (moderate-to-severe financial toxicity); mean IFDFW score was 4.3 (high financial stress). Financial consequences included post-cancer credit score decrease (44%), debt collection contact (39%), spending more than 10% of income on medical expenses (39%), and lacking money for basic necessities (23%). Financial coping behaviors included taking money from savings (55%), taking on credit card debt (45%), putting off major purchases (45%), and borrowing money (42%). In logistic regression models, general financial distress was associated with increased odds of experiencing financial consequences and engaging in both medical- and non-medical-related financial coping behaviors.

DISCUSSION

AYA survivors face long-term financial hardship after cancer treatment, which impacts multiple domains, including their use of healthcare and their personal finances. Interventions are needed to provide AYAs with tools to navigate financial aspects of the healthcare system; connect them with resources; and create systems-level solutions to address healthcare affordability.

IMPLICATIONS FOR CANCER SURVIVORS

Survivorship care providers, particularly those who interact with AYA survivors, must be attuned to the unique risk for financial hardships facing this population and make efforts to increase access available interventions.

Medicaid Expansion of the Patient Protection and Affordable Care Act and Participation of Patients With Medicaid in Cancer Clinical Trials

Importance

The Patient Protection and Affordable Care Act (ACA) Medicaid expansion resulted in increased use of Medicaid insurance nationwide. However, the association between Medicaid expansion and access to clinical trials has not been examined to date.

Objective

To examine whether the implementation of ACA Medicaid expansion was associated with increased participation of patients with Medicaid insurance in cancer clinical trials.

Design, Setting, and Participants

Data for this cohort study of 51 751 patients were from the SWOG Cancer Research Network. All patients aged 18 to 64 years and enrolled in treatment trials with Medicaid or private insurance between April 1, 1992, and February 29, 2020, were included. Interrupted time-series analysis with segmented logistic regression was used. The monthly unemployment rate and presidential administration were adjusted to reflect potential differences in Medicaid use associated with economic conditions and national administrative policies, respectively. Data analysis was conducted between June 22, 2021, and August 5, 2022.

Exposure

Implementation of Medicaid expansion on January 1, 2014, was the independent exposure variable.

Main Outcomes and Measures

The number and proportion of patients by insurance type enrolled in cancer clinical trials over time were analyzed.

Results

Overall, data for 51 751 patients were analyzed. Mean (SD) age was 50.6 (9.8) years, 67.3% of patients were female, 41.1% were younger than 50 years, and 9.1% used Medicaid. A 19% annual increase (odds ratio [OR], 1.19; 95% CI, 1.11-1.28; P < .001) was identified in the odds of patients using Medicaid after the ACA Medicaid expansion, resulting in a 52% increase (OR, 1.52; 95% CI, 1.29-1.78; P < .001) compared with what was expected in the number of Medicaid patients enrolled over time. The association was greater in states that adopted Medicaid expansion in 2014 to 2015 (OR, 1.26; 95% CI, 1.15-1.38; P < .001) compared with other states (OR, 1.08; 95% CI, 0.96-1.21; P = .20; P = .04 for interaction). By February 2020, the proportion of patients with Medicaid insurance was 17.8% (95% CI, 15.0%-20.8%; P < .001), whereas the expected proportion had ACA Medicaid expansion not occurred was 6.9% (95% CI, 4.4%-10.3%; P < .001).

Conclusions and Relevance

Findings suggest that implementation of ACA Medicaid expansion was associated with increased participation of patients using Medicaid in cancer clinical trials. Improved participation in clinical trials for Medicaid-insured patients is critical for socioeconomically vulnerable patients seeking access to the newest treatments available in trials and for improving confidence that trial findings apply to patients of all backgrounds.

Health insurance status and cancer stage at diagnosis and survival in the United States

Previous studies using data from the early 2000s demonstrated that patients who were uninsured were more likely to present with late-stage disease and had worse short-term survival after cancer diagnosis in the United States. In this report, the authors provide comprehensive data on the associations of health insurance coverage type with stage at diagnosis and long-term survival in individuals aged 18-64 years who were diagnosed between 2010 and 2013 with 19 common cancers from the National Cancer Database, with survival follow-up through December 31, 2019. Compared with privately insured patients, Medicaid-insured and uninsured patients were significantly more likely to be diagnosed with late-stage (III/IV) cancer for all stageable cancers combined and separately. For all stageable cancers combined and for six cancer sites-prostate, colorectal, non-Hodgkin lymphoma, oral cavity, liver, and esophagus-uninsured patients with Stage I disease had worse survival than privately insured patients with Stage II disease. Patients without private insurance coverage had worse short-term and long-term survival at each stage for all cancers combined; patients who were uninsured had worse stage-specific survival for 12 of 17 stageable cancers and had worse survival for leukemia and brain tumors. Expanding access to comprehensive health insurance coverage is crucial for improving access to cancer care and outcomes, including stage at diagnosis and survival.

Navigating financial toxicity in patients with cancer: A multidisciplinary management approach

Approximately one-half of individuals with cancer face personal economic burdens associated with the disease and its treatment, a problem known as financial toxicity (FT). FT more frequently affects socioeconomically vulnerable individuals and leads to subsequent adverse economic and health outcomes. Whereas multilevel systemic factors at the policy, payer, and provider levels drive FT, there are also accompanying intervenable patient-level factors that exacerbate FT in the setting of clinical care delivery. The primary strategy to intervene on FT at the patient level is financial navigation. Financial navigation uses comprehensive assessment of patients' risk factors for FT, guidance toward support resources, and referrals to assist patient financial needs during cancer care. Social workers or nurse navigators most frequently lead financial navigation. Oncologists and clinical provider teams are multidisciplinary partners who can support optimal FT management in the context of their clinical roles. Oncologists and clinical provider teams can proactively assess patient concerns about the financial hardship and employment effects of disease and treatment. They can respond by streamlining clinical treatment and care delivery planning and incorporating FT concerns into comprehensive goals of care discussions and coordinated symptom and psychosocial care. By understanding how age and life stage, socioeconomic, and cultural factors modify FT trajectory, oncologists and multidisciplinary health care teams can be engaged and informative in patient-centered, tailored FT management. The case presentations in this report provide a practical context to summarize authors' recommendations for patient-level FT management, supported by a review of key supporting evidence and a discussion of challenges to mitigating FT in oncology care. CA Cancer J Clin. 2022;72:437-453.

The Affordable Care Act's young adult mandate was associated with a reduction in pain prevalence

ABSTRACT

Pain is a major health problem among U.S. young adults. The passage of the Affordable Care Act's young adult mandate in 2010 allowed individuals to remain on their parents' health insurance until age 26. Although studies have documented the positive effects of this mandate on various health outcomes, less is known about its association with self-reported pain among young adults. Using the 2002 to 2018 National Health Interview Survey (N = 48,053) and a difference-in-differences approach, we compared the probabilities of reporting pain at 5 sites (low back, joint, neck, headache/migraine, and facial/jaw) and the number of pain sites between mandate eligible (ages 20-25) and ineligible (ages 26-30) adults before and after the mandate. In fully adjusted models, the mandate was associated with a decline of 2 percentage points in the probability of reporting pain at any site (marginal effect, -0.02; 95% confidence interval [CI], -0.05 to -0.002; weighted sample proportion, 0.37) and in the number of pain sites (coefficient, -0.07; 95% CI, -0.11 to -0.01; weighted sample average, 0.62). These results were primarily driven by the association between the mandate and the probability of reporting low back pain (marginal effect, -0.03; 95% CI, -0.05 to -0.01; weighted sample proportion, 0.20). Additional analyses revealed that the mandate was associated with improvements in access to care and reductions in risk factors for pain-including chronic conditions and risky health behaviors. To the extent that the results are generalizable to other health insurance programs, removing financial barriers to medical care may help reduce pain prevalence.

Toward a transitional care from childhood and adolescence to adulthood in surgical neurooncology? A lesson from the Necker-Enfants Malades and the Sainte-Anne Hospitals collaboration

OBJECTIVE

Transitional care in surgical neurooncology is poorly studied. However, this period is pivotal, since it allows the patient to be empowered in his or her disease management. Here, the authors describe the experience of the Necker-Enfants Malades and the Sainte-Anne Hospital collaboration.

METHODS

The mixed transitional consultations started in September 2019 in a dedicated space for transitional care, named the "La Suite" department, located in the Necker-Enfants Malades Hospital, Paris, France. The authors organized planned consultations to schedule the clinical and radiological follow-up in the adult neurosurgical department but also emergency consultations to manage tumor recurrence in young adult patients. Transitional care was performed jointly by pediatric and adult neurosurgeons who have developed clinical and research skills in the field of surgical neurooncology. Neuropathological analysis was performed by a neuropathologist who is specialized in pediatric and adult neurooncology.

RESULTS

Fourteen patients benefited from a mixed transitional consultation. All of them accepted to start their management in an adult neurosurgical environment. Eleven patients (78.6%) for whom the disease was controlled benefited from a planned consultation. Three patients (21.4%) required rapid neurosurgical management for a tumor recurrence (n = 2) or for a new primary CNS tumor (n = 1) and benefited from an emergency consultation.

CONCLUSIONS

For adult patients harboring a brain tumor during childhood or adolescence, the authors suggest that neurosurgeons specialized in adult surgical neurooncology with a full knowledge in pediatric neurooncology will combine the required skills to optimize care management for these patients within a dedicated multidisciplinary organization framework.

The impact of the dependent care provision on individuals with spina bifida transitioning to adulthood

INTRODUCTION

Under the Affordable Care Act, the Dependent Care Provision (DCP) was enacted in 2010 and expanded healthcare coverage for millions of young adults ages 19-25 by allowing them to stay on their parents' insurance until age 26. It is unknown whether the DCP has impacted young adults with SB who are at risk for lapses in insurance coverage as they transition into adult care.

OBJECTIVE

Our aim was to determine the impact of the DCP on access to care (insurance status) and healthcare-quality (hospital admissions for potentially preventable conditions).

METHODS

Using the National Inpatient Sample (an all-payor national dataset of hospital admissions), we analyzed pre/post DCP changes for admissions of SB patients ages 19-25. Our outcomes of interest were rates of insurance coverage and proportion of admissions due to potentially preventable conditions (UTI, pyelonephritis, skin conditions, osteomyelitis, sepsis, and pneumonia). Analysis included a difference-in-differences logistic regression model which compared the pre/post DCP difference (2006-s quarter of 2010 vs. 2011-2013) in patients ages 19-25 to the difference in patients ages 26-32 who were ineligible for the DCP policy.

RESULTS

For admissions of SB patients ages 19-25, the DCP was not associated with improved insurance status compared to admissions ages 26-32 (0% vs. -0.4%, p = 0.10) and rates of private insurance decreased in both age groups, but more so in ages 26-32 (-2.0% vs. -3.9%, p < 0.001). Private insurance rates increased for admissions of white patients ages 19-25 but not for black and Hispanic groups. An increase in overall insurance status was also seen in young adults from high-income zip codes. Admissions for potentially preventable conditions increased in both age groups by a similar degree (+2.6% vs. +2.5%, p = 0.82).

DISCUSSION

Under the Affordable Care Act, the DCP failed to improve rates of private insurance or decrease rates of noninsurance for admissions of young adults with SB. Certain race and socioeconomic groups benefited more from this national healthcare policy. Meanwhile, admissions for potentially preventable conditions are common in spina bifida patients, and increased over the study period, suggesting a need for further investigation into optimizing the delivery of healthcare to this complex patient population.

CONCLUSION

The DCP did not result in improved overall insurance rates or in improved rates of private insurance for admissions of SB patients 18-25 years old.

Expenditures among young adults with acute lymphoblastic leukemia by site of care

BACKGROUND

Individuals diagnosed with acute lymphoblastic leukemia (ALL) between the ages of 22 and 39 years experience worse outcomes than those diagnosed when they are 21 years old or younger. Treatment at National Cancer Institute-designated Comprehensive Cancer Centers (CCC) mitigates these disparities but may be associated with higher expenditures.

METHODS

Using deidentified administrative claims data (OptumLabs Data Warehouse), the cancer-related expenditures were examined among patients with ALL diagnosed between 2001 and 2014. Multivariable generalized linear model with log-link modeled average monthly health-plan-paid (HPP) expenditures and amount owed by the patient (out-of-pocket [OOP]). Cost ratios were used to calculate excess expenditures (CCC vs non-CCC). Incidence rate ratios (IRRs) compared CCC and non-CCC monthly visit rates. Models adjusted for sociodemographics, comorbidities, adverse events, and months enrolled.

RESULTS

Clinical and sociodemographic characteristics were comparable between CCC (n = 160) and non-CCC (n = 139) patients. Higher monthly outpatient expenditures in CCC patients ($15,792 vs $6404; P < .001) were driven by outpatient hospital HPP expenditures. Monthly visit rates and per visit expenditures for nonchemotherapy visits (IRR = 1.6; P = .001; CCC = $8247, non-CCC = $1191) drove higher outpatient hospital expenditures among CCCs. Monthly OOP expenditures were higher at CCCs for outpatient care (P = .02). Inpatient HPP expenditures were significantly higher at CCCs ($25,918 vs $13,881; ꞵ = 0.9; P < .001) before accounting for adverse events but were no longer significant after adjusting for adverse events (ꞵ = 0.4; P = .1). Hospitalizations and length of stay were comparable.

CONCLUSIONS

Young adults with ALL at CCCs have higher expenditures, likely reflecting differences in facility structure, billing practices, and comprehensive patient care. It would be reasonable to consider CCCs comparable to the oncology care model and incentivize the framework to achieve superior outcomes and long-term cost savings.

LAY SUMMARY

Health care expenditures in young adults (aged 22-39 years) with acute lymphoblastic leukemia (ALL) are higher among patients at National Cancer Institute-designated Comprehensive Cancer Centers (CCC) than those at non-CCCs. The CCC/non-CCC differences are significant among outpatient expenditures, which are driven by higher rates of outpatient hospital visits and outpatient hospital expenditures per visit at CCCs. Higher expenditures and visit rates of outpatient hospital visits among CCCs may also reflect how facility structure and billing patterns influence spending or comprehensive care. Young adults at CCCs face higher inpatient HPP expenditures; these are driven by serious adverse events.

Socioeconomic and Demographic Variation in Insurance Coverage Among Patients With Head and Neck Cancer After the Affordable Care Act

Importance

Health insurance status has a significant association with early diagnosis and stage at presentation, which are the most important predictors of survival among patients with head and neck cancer (HNC). Literature on the association of the Patient Protection and Affordable Care Act (ACA) with changes in insurance status among patients with HNC remains limited. To our knowledge, no studies have evaluated changes in insurance rates across sociodemographic subgroups of patients with HNC.

Objective

To assess the association of the implementation of the ACA with insurance status across socioeconomic and demographic subpopulations of patients with HNC.

Design, Setting, and Participants

A retrospective cohort study using data from the National Cancer Database (NCDB), a hospital-based cancer registry (2011-2015) for adults diagnosed with a malignant primary HNC was carried out. The analyses were conducted from November 2018 through December 2018.

Main Outcomes and Measures

Changes in the percentage of patients with insurance.

Results

A total of 131 779 patients with HNC were identified in the pre-ACA (77 071) and post-ACA (54 708) periods. Overall, 98 207 (74.5%) participants were men and 33 572 (25.5) were women, with 73 124 (55.5%) being aged between 50 to 64 years. There was a 2.68 percentage point decrease (PPD) (95% CI, 2.93-2.42) in the percentage of patients with HNC without insurance from the pre-ACA to the post-ACA period. Changes in the percentage of uninsured patients varied significantly by age, with the largest reduction in uninsured status among patients with HNC aged 18 to 34 years (5.12 PPD; 95% CI, 3.18-7.06) and the smallest reduction in uninsured among those aged 65 to 74 years (0.24 PPD; 95% CI, 0.03-0.45). There was a significantly greater reduction in uninsured status in low-income zip codes (3.45 PPD; 95% CI, 2.76-4.14) than in high-income zip codes (1.99 PPD; 95% CI, 1.63-2.36).

Conclusions and Relevance

There was a significant association between ACA implementation and percentage decrease in uninsured patients. Young adults and those residing in low-income zip codes experienced a significantly higher rate of insurance uptake compared with older adults and residents of high-income areas. This suggests that coverage expansions enacted through the ACA are not only associated with increased access to care among the broader HNC population, but that they may also yield a greater benefit among subpopulations with historically limited insurance coverage.

Impact of Dependent Coverage Provision of the Affordable Care Act on Insurance Continuity for Adolescents and Young Adults With Cancer

PURPOSE

The 2010 Dependent Coverage Provision (DCP) of the Affordable Care Act (ACA) allowed enrollees to remain on their parents' health insurance until 26 years of age. We compared rates of insurance disenrollment among patients with cancer who were DCP-eligible at age 19 to those who were not eligible at age 19.

METHODS

Using OptumLabs Data Warehouse, which contains longitudinal, real-world, de-identified administrative claims for commercial enrollees, we examined patients born between 1982 and 1993 and diagnosed with cancer between 2000 and 2015. In the recent cohort, patients who turned 19 in 2010-2012 (DCP-eligible to stay on parents' insurance) were matched to patients who turned 19 in 2007-2009 (not DCP-eligible when turning 19). In an earlier control cohort, patients who turned 19 between 2004 and 2006 (not DCP-eligible) were matched to patients who turned 19 between 2001 and 2003 (not DCP-eligible). Patients were matched on cancer type, diagnosis date, demographics, and treatment characteristics. The time to loss of coverage was estimated using Cox models. Difference-in-difference between the recent and earlier cohorts was also evaluated.

RESULTS

A total of 2,829 patients who turned 19 years of age in 2010-2012 were matched to patients who turned 19 in 2007-2009. Median time to disenrollment was 26 months for younger patients versus 22 months for older patients (hazard ratio [HR], 0.85; 95% CI, 0.80 to 0.90; P = .001). In 8,978 patients who turned 19 between 2001 and 2006, median time to disenrollment was 20 months among both younger and older patients (HR, 0.99; 95% CI, 0.94 to 1.03; P = .59). The difference between the recent cohort and the earlier control cohort was a 15% greater reduction in coverage loss (P < .0001), favoring those turning 19 after the DCP went into effect.

CONCLUSION

In the vulnerable population of adolescent and young adult cancer survivors, the ACA may have lowered the insurance dropout rate.

Is Surgical Resection of the Primary Site Associated with an Improved Overall Survival for Patients with Primary Malignant Bone Tumors Who Have Metastatic Disease at Presentation?

BACKGROUND

The management of primary malignant bone tumors in patients with metastatic disease at presentation remains a challenge. Although surgical resection has been a mainstay in the management of nonmetastatic malignant bone tumors, there is a lack of large-scale evidence-based guidance on whether surgery of the primary site/tumor improves overall survival in malignant bone tumors with metastatic disease at presentation.

QUESTIONS/PURPOSES

(1) Is surgical resection of the primary tumor associated with improved overall survival in patients with primary malignant bone tumors who have metastatic disease at presentation? (2) What other factors are associated with improved and/or poor overall survival?

METHODS

The 2004 to 2016 National Cancer Database (NCDB), a national registry containing data from more than 34 million cancer patients in the United States, was queried using International Classification of Diseases, 3rd Edition, topographical codes to identify patients with primary malignant bone tumors of the extremities (C40.0-C40.3, C40.8, and C40.9) and/or pelvis (C41.4). The NCDB was preferred over other national cancer registries (that is, the Surveillance, Epidemiology, and End Results database) because it includes a specific variable that codes for patients who received additional surgeries at metastatic sites. Patients with malignant bone tumors of the head or skull, trunk, and spinal column were excluded because these patients are not routinely encountered and treated by orthopaedic oncologists. Histologic codes were used to categorize the tumors into the following groups: osteosarcomas, chondrosarcomas, and Ewing sarcomas. Patients whose tumors were classified as Stage 1, 2, or 3 based on American Joint Commission of Cancer guidelines were excluded. Only patients who presented with metastatic disease were included in the final study sample. The study sample was divided into two distinct groups: those who underwent surgical resection of the primary tumor and those who did not receive any operation for the primary tumor. A total of 2288 patients with primary malignant bone tumors (1121 osteosarcomas, 345 chondrosarcomas, and 822 Ewing sarcomas) with metastatic disease at presentation were included, of whom 46% (1053 of 2288) underwent surgical resection of the primary site. Thirty-three percent (348 of 1053) of patients undergoing surgical resection of the primary site also underwent additional resection of metastases. Patients undergoing surgical resection of the primary site typically were younger than 18 years, lived further from a facility, had tumors involving the upper or lower extremity, had a diagnosis of osteosarcoma or chondrosarcoma, and had a greater tumor size and higher tumor grade at presentation. To account for baseline differences within the patient population and to adjust for additional confounding variables, multivariate Cox regression analyses were used to assess whether undergoing surgical resection of the primary tumor was associated with improved overall survival, after controlling for differences in baseline demographics, tumor characteristics (grade, location, histologic type, and tumor size), and treatment patterns (resection of distant or regional metastatic sites, positive or negative surgical margins, and use of radiation therapy or chemotherapy). Additional sensitivity analyses, stratified by histologic type for osteosarcomas, chondrosarcomas, and Ewing sarcomas, were used to assess factors associated with overall survival for each tumor type.

RESULTS

After controlling for differences in baseline demographics, tumor characteristics, and treatment patterns, we found that surgical resection of the primary site was associated with reduced overall mortality compared with those who did not have a resection of the primary site (hazard ratio 0.42 [95% confidence interval 0.36 to 0.49]; p < 0.001). Among other factors, in the stratified analysis, radiation therapy was associated with improved overall survival for patients with Ewing sarcoma (HR 0.71 [95% CI 0.57 to 0.88]; p = 0.002) but not for those with osteosarcoma (HR 1.14 [95% CI 0.91 to 1.43]; p = 0.643) or chondrosarcoma (HR 1.0 [95 % CI 0.78 to 1.50]; p = 0.643). Chemotherapy was associated with improved overall survival for those with osteosarcoma (HR 0.50 [95% CI 0.39 to 0.64]; p < 0.001) and those with chondrosarcoma (HR 0.62 [95% CI 0.45 to 0.85]; p = 0.003) but not those with Ewing sarcoma (HR 0.7 [95% CI 0.46 to 1.35]; p = 0.385).

CONCLUSIONS

Surgical resection of the primary site was associated with an overall survival advantage in patients with primary malignant bone tumors who presented with metastatic disease. Further research, using more detailed data on metastatic sites (such as, size, location, number, and treatment), chemotherapy regimen and location of radiation (primary or metastatic site) is warranted to better understand which patients will have improved overall survival and/or a benefit in the quality of life from resecting their primary malignant tumor if they present with metastatic disease at diagnosis.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Insurance coverage, stage at diagnosis, and time to treatment following dependent coverage and Medicaid expansion for men with testicular cancer

Introduction

We sought to assess the impact of Affordable Care Act Dependent Care Expansion (ACA-DCE), which allowed dependent coverage for adults aged 19–25, and Medicaid expansion on outcomes for men with testicular cancer.

Methods

Using a US-based cancer registry, we performed adjusted difference-in-difference (DID) analyses comparing outcomes between men aged 19–25 (n = 8,026) and 26–64 (n = 33,303) pre- (2007–2009) and post-ACA-DCE (2011–2016) and between men in states that expanded Medicaid (n = 2,296) to men in those that did not (n = 2,265)pre- (2011–2013) and post-Medicaid expansion (2015–2016).

Results

In ACA-DCE analysis, rates of uninsurance decreased (DID -5.64, 95% confidence interval [CI] -7.23 to -4.04%, p<0.001) among patients aged 19–25 relative to older patients aged 26–64. There was no significant DID in advanced stage at diagnosis (stage≥II; p = 0.6) or orchiectomy more than 14 days after diagnosis (p = 0.6). For patients who received chemotherapy or radiotherapy as their first course of treatment, treatment greater than 60 days after diagnosis decreased (DID -4.84%, 95% CI -8.22 to -1.45%, p = 0.005) among patients aged 19–25 relative to patients aged 26–64. In Medicaid expansion states, rates of uninsurance decreased (DID -4.20%, 95% CI -7.67 to -0.73%, p = 0.018) while patients receiving chemotherapy or radiotherapy greater than 60 days after diagnosis decreased (DID -8.76, 95% CI -17.13 to -0.38%, p = 0.040) compared to rates in non-expansion states. No significant DIDs were seen for stage (p = 0.8) or time to orchiectomy (p = 0.1).

Conclusions

Men with testicular cancer had lower uninsurance rates and decreased time to delivery of chemotherapy or radiotherapy following ACA-DCE and Medicaid expansions. Time to orchiectomy and stage at diagnosis did not change following either insurance expansion.

State Medicaid expansion status, insurance coverage and stage at diagnosis in head and neck cancer patients

OBJECTIVES

Only one in three head and neck cancer (HNC) patients present with early-stage disease. We aimed to quantify associations between state Medicaid expansions and changes in insurance coverage rates and stage at diagnosis of HNC.

METHODS

Using a quasi-experimental difference-in-differences (DID) approach and data from 26,330 cases included in the Surveillance, Epidemiology, and End Results program (2011-2015), we retrospectively examined changes in insurance coverage and stage at diagnosis of adult HNC in states that expanded Medicaid (EXP) versus those that did not (NEXP).

RESULTS

There was a significant increase in Medicaid coverage in EXP (+1.6 percentage point (PP) versus) vs. NEXP (-1.8 PP) states (3.36 PP, 95% CI = 1.32, 5.41; p = 0.001), and this increase was mostly among residents of low income and education counties. We also observed a reduction in uninsured rates among HNC patients in low income counties (-4.17 PP, 95% CI = -6.84, -1.51; p = 0.002). Overall, early stage diagnosis rates were 28.3% (EXP) vs. 26.7% (NEXP), with significant increases in early stage diagnosis post-Medicaid expansion among young adults, 18-34 years (17.2 PP, 95% CI - 1.34 to 33.1, p = 0.034), females (7.54 PP, 95% CI = 2.00 to 13.10, p = 0.008), unmarried patients (3.83 PP, 95% CI = 0.30-7.35, p = 0.033), and patients with lip cancer (13.5 PP, 95% CI = 2.67-24.3, p = 0.015).

CONCLUSIONS

Medicaid expansion is associated with improved insurance coverage rates for HNC patients, particularly those with low income, and increases in early stage diagnoses for young adults and women.

Impact of Health Insurance on Stage at Cancer Diagnosis Among Adolescents and Young Adults

BACKGROUND

Uninsured adolescents and young adults (AYAs) and those with publicly funded health insurance are more likely to be diagnosed with cancer at later stages. However, prior population-based studies have not distinguished between AYAs who were continuously uninsured from those who gained Medicaid coverage at the time of cancer diagnosis.

METHODS

AYA patients (ages 15-39 years) with nine common cancers diagnosed from 2005 to 2014 were identified using California Cancer Registry data. This cohort was linked to California Medicaid enrollment files to determine continuous enrollment, discontinuous enrollment, or enrollment at diagnosis, with other types of insurance determined from registry data. Multivariable logistic regression was used to evaluate factors associated with later stages at diagnosis.

RESULTS

The majority of 52 774 AYA cancer patients had private or military insurance (67.6%), followed by continuous Medicaid (12.4%), Medicaid at diagnosis (8.5%), discontinuous Medicaid (3.9%), other public insurance (1.6%), no insurance (2.9%), or unknown insurance (3.1%). Of the 13 069 with Medicaid insurance, 50.1% were continuously enrolled. Compared to those who were privately insured, AYAs who enrolled in Medicaid at diagnosis were 2.2-2.5 times more likely to be diagnosed with later stage disease, whereas AYAs discontinuously enrolled were 1.7-1.9 times and AYAs continuously enrolled were 1.4-1.5 times more likely to be diagnosed with later stage disease. Males, those residing in lower socioeconomic neighborhoods, and AYAs of Hispanic or black race and ethnicity (vs non-Hispanic white) were more likely to be diagnosed at a later stage, independent of insurance.

CONCLUSIONS

Our findings suggest that access to continuous medical insurance is important for decreasing the likelihood of late stage cancer diagnosis.

The Affordable Care Act and access to care across the cancer control continuum: A review at 10 years

Lack of health insurance coverage is strongly associated with poor cancer outcomes in the United States. The uninsured are less likely to have access to timely and effective cancer prevention, screening, diagnosis, treatment, survivorship, and end-of-life care than their counterparts with health insurance coverage. On March 23, 2010, the Patient Protection and Affordable Care Act (ACA) was signed into law, representing the largest change to health care delivery in the United States since the introduction of the Medicare and Medicaid programs in 1965. The primary goals of the ACA are to improve health insurance coverage, the quality of care, and patient outcomes, and to maintain or lower costs by catalyzing changes in the health care delivery system. In this review, we describe the main components of the ACA, including health insurance expansions, coverage reforms, and delivery system reforms, provisions within these components, and their relevance to cancer screening and early detection, care, and outcomes. We then highlight selected, well-designed studies examining the effects of the ACA provisions on coverage, access to cancer care, and disparities throughout the cancer control continuum. Finally, we identify research gaps to inform evaluation of current and emerging health policies related to cancer outcomes.

Taboo Topics in Adolescent and Young Adult Oncology: Strategies for Managing Challenging but Important Conversations Central to Adolescent and Young Adult Cancer Survivorship

Research on adolescents and young adults (AYAs) with cancer has flourished over the past decade, underscoring the unique medical and psychosocial needs of this vulnerable group. A cancer diagnosis during adolescence and young adulthood intersects with the developmental trajectory of AYAs, derailing critical physical, social, and emotional development. AYAs face these abrupt life changes needing age-appropriate information and resources to offset these challenges. Greater attention is needed to address AYA-specific concerns on reproductive and sexual health, financial security and independence, emotional well-being, social support, and end-of-life care. If these unique needs are unaddressed, this can adversely affect AYAs' health care engagement and overall quality of life, increasing their risk for cancer-related morbidity and early mortality. In particular, health care decisions made during treatment have important implications for AYA patients' future health. Oncology clinicians are well positioned to address AYA patients' concerns by anticipating and addressing the challenges this age group is likely to face. In this paper, we explore several core topics that affect AYAs' quality of life and that can be challenging to address. Starting from the moment of diagnosis, through cancer treatment and post-treatment survivorship, and into end of life, each section highlights critical developmental-centric life domains that are affected by the cancer experience. Specifically, we discuss resources, tools, and strategies to navigate these challenging conversations. Taking a risk-reduction approach that invites two-way communication and facilitates referral to age-appropriate resources would help destigmatize these experiences and, in turn, would support the provision of compassionate and effective age-concordant care to this vulnerable group.

Age-Related Differences in Financial Toxicity and Unmet Resource Needs Among Adolescent and Young Adult Cancer Patients

Financial toxicity may differ by age at diagnosis between adolescents and young adults (AYAs) with cancer. We surveyed 52 AYA cancer patients about unmet needs and financial toxicity using the COmprehensive Score for financial Toxicity (COST). We compared outcomes by age at diagnosis (15-25-year olds [n = 25, 48%] vs. 26-39-year olds [n = 27, 52%]). AYAs diagnosed ages 26-39 reported that cancer negatively affected their finances more than 15-25-year olds (77.8% vs. 37.5%, p = 0.0005). Lower mean COST scores among those diagnosed ages 26-39 indicated greater financial toxicity compared to those 15-25 years (18.22 vs. 24.84, p = 0.02). Financial burden appears to be greater for older AYAs with cancer.

Material and psychological financial hardship related to employment disruption among female adolescent and young adult cancer survivors

BACKGROUND

The importance of addressing adverse financial effects of cancer among adolescents and young adults (AYAs) is paramount as survival improves. In the current study, the authors examined whether cancer-related employment disruption was associated with financial hardship among female AYA cancer survivors in North Carolina and California.

METHODS

AYA cancer survivors identified through the North Carolina Central Cancer Registry and the Kaiser Permanente Northern/Southern California tumor registries responded to an online survey. Disrupted employment was defined as reducing hours, taking temporary leave, or stopping work completely because of cancer. Financial hardship was defined as material conditions or psychological distress related to cancer. Descriptive statistics and chi-square tests were used to characterize the invited sample and survey respondents. Marginal structural binomial regression models were used to estimate prevalence differences (PDs) and 95% confidence intervals (95% CIs).

RESULTS

Among 1328 women employed at the time of their diagnosis, women were a median age of 34 years at the time of diagnosis and 7 years from diagnosis at the time of the survey and approximately 32% experienced employment disruption. A substantial percentage reported financial hardship related to material conditions (27%) or psychological distress (50%). In adjusted analyses, women with disrupted employment had a 17% higher burden of material conditions (95% CI, 10%-23%) and an 8% higher burden of psychological distress (95% CI, 1%-16%) compared with those without disruption.

CONCLUSIONS

Financial hardship related to employment disruption among female AYA cancer survivors can be substantial. Interventions to promote job maintenance and transition back to the workforce after treatment, as well as improved workplace accommodations and benefits, present an opportunity to improve cancer survivorship.

Insurance impacts survival for children, adolescents, and young adults with bone and soft tissue sarcomas

Background

While racial/ethnic survival disparities have been described in pediatric oncology, the impact of income has not been extensively explored. We analyzed how public insurance influences 5‐year overall survival (OS) in young patients with sarcomas.

Methods

The University of California San Francisco Cancer Registry was used to identify patients aged 0‐39 diagnosed with bone or soft tissue sarcomas between 2000 and 2015. Low‐income patients were defined as those with no insurance or Medicaid, a means‐tested form of public insurance. Survival curves were computed using the Kaplan‐Meier method and compared using log‐rank tests and Cox models. Causal mediation was used to assess whether the association between public insurance and mortality is mediated by metastatic disease.

Results

Of 1106 patients, 39% patients were classified as low‐income. Low‐income patients were more likely to be racial/ethnic minorities and to present with metastatic disease (OR 1.96, 95% CI 1.35‐2.86). Low‐income patients had significantly worse OS (61% vs 71%). Age at diagnosis and extent of disease at diagnosis were also independent predictors of OS. When stratified by extent of disease, low‐income patients consistently had significantly worse OS (localized: 78% vs 84%, regional: 64% vs 73%, metastatic: 23% vs 30%, respectively). Mediation analysis indicated that metastatic disease at diagnosis mediated 15% of the effect of public insurance on OS.

Conclusions

Low‐income patients with bone and soft tissue sarcomas had decreased OS regardless of disease stage at presentation. The mechanism by which insurance status impacts survival requires additional investigation, but may be through reduced access to care.

Coverage, Financial Burden, and the Patient Protection and Affordable Care Act for Patients With Cancer

PURPOSE:

Evidence suggests coverage has improved significantly for patients with cancer, particularly in the lower-income population, after the implementation of the Affordable Care Act (ACA). Yet no study has examined changes in type of coverage or the resulting effect on spending and financial burden.

METHODS:

Using 2011 to 2015 Medical Expenditure Panel Survey data, we examine changes in type of coverage, spending, and financial burden among lower-income (< 400% of federal poverty level [FPL]) individuals diagnosed with cancer after the ACA. To better understand the changes, we compare this sample to the lower-income patients without cancer and patients with cancer with a higher income (≥ 400% of FPL). All analyses were conducted in 2018.

RESULTS:

In adjusted analyses, we found a decline in months uninsured (−0.78 months; P = .001) and an increase in months with Medicaid coverage (0.40 months; P = .059) among the lower-income patients with cancer. This change is similar to the lower-income patients without cancer. We found an increase in total expenditures ($3,020; P = .071) but a modest decline in the fraction of family income spent on health (−0.014; P = 0.099), although neither is statistically significant. For the higher income patients with cancer, we observed significant increases in both out-of-pocket premiums and medical financial burden.

CONCLUSION:

After the ACA, lower-income people diagnosed with cancer experienced significant gains in coverage largely through Medicaid at rates similar to lower-income patients without cancer, but patients with cancer with incomes 400% or greater of FPL faced a higher financial burden.

Impact of the affordable care act dependent coverage provision on young adult cancer patient insurance coverage by sociodemographic and economic characteristics

PURPOSE

To evaluate the impact of the Affordable Care Act Dependent Care Provision by sociodemographic and economic characteristics in young adult cancer patients.

METHODS

The National Cancer Database (NCDB) and the Surveillance, Epidemiology, and End Results (SEER) 18 database were queried for young adult cancer cases diagnosed during 2007-2014. Using a difference-in-differences approach, we examined insurance coverage in different subgroups of policy-eligible 19-25 year-olds versus policy-ineligible 27-29 year-olds from the pre- (2007-2009) to post- (2011-2014) Dependent Care Provision period.

RESULTS

Across subgroups and study populations, insurance coverage increased significantly following the Provision enactment in the policy-eligible versus policy-ineligible group across most subgroups (range in NCDB: 1.83 to 6.38% for low and mid-low education areas, respectively; range in SEER: 1.43 to 6.18 for Non-Hispanic Others and Hispanics, respectively). Heterogenous impacts were observed by sex with a larger impact in males (NCDB: 5.14%, 95% CI 3.59-6.69; SEER: 4.46, 2.12-6.8) than females (NCDB: 2.51%, 95% CI 1.39-3.62; SEER: 2.50, 0.82-4.18). We observed no other statistical evidence for Dependent Care Provision subgroup heterogeneity except for a smaller impact in individuals from low education areas in NCDB.

CONCLUSIONS

Our results indicate a positive Dependent Care Provision impact on insurance coverage in young adults with cancer across subgroups, with evidence for a smaller impact in females relative to males and in low relative to high education areas.

Insurance status is related to overall survival in patients with small intestine adenocarcinoma: A population-based study

BACKGROUND

Our goal was to investigate the effect of insurance status on the overall survival (OS) in cases of small intestine adenocarcinoma.

METHODS

The SEER (Surveillance, Epidemiology, and End Results) database was used to identify 3822 patients who were diagnosed with small intestine adenocarcinoma between 2007 and 2015. The proportional hazard ASSUMPTION was evaluated by proportional-hazards assumption test and Schoenfeld residual test. The Kaplan-Meier method and Cox proportional-hazards regression analysis were performed to evaluate the association between insurance status and OS.

RESULTS

We found that the insurance status at the time of diagnosis affected OS at the population level, both in those aged <65 and ≥65 years. Cox multivariate analysis of patients aged <65 years revealed that the hazard of death was greater in the Medicaid group (hazard ratio [HR] = 1.641, 95% confidence interval [CI] = 1.299-2.073, P < 0.001] and uninsured group (HR = 1.472, 95% CI = 1.095-1.979, P = 0.010) compared with the insured group, while the OS did not differ significantly between the Medicaid and uninsured groups. Similarly, the hazard of death among patients aged ≥65 years was higher in the Medicaid than the insured group (HR = 1.403, 95% CI = 1.136-1.733, P = 0.002).

CONCLUSION

Our results suggest that patients with small intestine adenocarcinoma with insurance coverage have a significantly better OS than patients who have Medicaid or are uninsured, while the OS does not differ between Medicaid and uninsured patients.

Understanding, measuring, and addressing the financial impact of cancer on adolescents and young adults

The financial impact of cancer treatment among adolescents and young adults (AYAs, 15-39 years) is deep and long lasting. Compared with other age groups, because of their life stage, AYAs are particularly vulnerable to the adverse economic effects of cancer treatment, also known as financial toxicity. Clinical manifestations of cancer-related financial toxicity include interrupted work and income loss, accumulated debt, treatment nonadherence, avoidance of medical care, and social isolation. Effective clinical interventions should include efforts to increase financial self-efficacy as well as direct support. Measures that are valid, reliable, multidimensional, and age-appropriate are needed to study and address financial toxicity in the AYA population.

Impacts of the Affordable Care Act Dependent Coverage Provision on Young Adults With Cancer

INTRODUCTION

Evidence through 2012 suggests that the 2010 Affordable Care Act Dependent Coverage Provision, extending dependent insurance coverage eligibility to age 26years, increased young adult insurance coverage and decreased cancer diagnosis stage in young adult cancer patients. This study examines Dependent Coverage Provision-associated changes in insurance coverage and diagnosis stage through 2014 in young adult cancer patients.

METHODS

Using a quasi-experimental study design, analyses were conducted in 2017-2018 using 2007 to 2014 data from the Surveillance, Epidemiology, and End Results (SEER) 18 and the National Cancer Database (NCDB). Using difference-in-differences analyses applied to linear probability models, changes in the percentage of policy-eligible individuals aged 19-25years versus ineligible individuals aged 27-29years who were insured (excluding Medicaid) and diagnosed at early (Stages 0 and 1) or late (Stage 4) stages following Dependent Coverage Provision enactment were estimated.

RESULTS

A total of 36,901 and 92,358 young adults were included from SEER and NCDB. Consistent increases in the percentage insured (SEER: 3.45 percentage points, 95% CI=2.04, 4.87; NCDB: 3.72 percentage points, 95% CI=2.80, 4.64); variable increases in early-stage diagnoses (2.25 percentage points, 95% CI=0.40, 4.10; 0.69 percentage points, 95% CI= -0.65, 2.02); and decreases in late-stage diagnoses (-1.74 percentage points, 95% CI= -3.10, -0.38; -0.58 percentage points, 95% CI= -1.46, 0.30) were observed in young adults aged 19-25 versus 27-29years.

CONCLUSIONS

These results provide clear evidence for a Dependent Coverage Provision-associated impact on insurance coverage in young adult cancer patients; however, clear impacts on diagnosis stage are less evident.

Adolescent and young adult cancer care: Financial hardship and continued uncertainty

Since 2005, there has been a steady increase in the number of new cancer diagnoses among adolescents and young adults (AYA) in the United States (US), likely due to improved awareness and detection within this age group, as well as the possible contribution of insurance expansion under the Patient Protection and Affordable Care Act. AYAs with cancer remain highly vulnerable financially, a situation that will only worsen with proposed rollbacks in access to and affordability of healthcare. In this review, we will discuss existing aspects of financial hardship and highlight areas of uncertainty, based on the current US political climate.

Patterns of Coverage Gains Among Young Adult Cancer Patients Following the Affordable Care Act

The dependent coverage expansion (DCE) and Medicaid expansions (ME) under the Affordable Care Act (ACA) may differentially affect eligibility for health insurance coverage in young adult cancer patients. Studies examining temporal patterns of coverage changes in young adults following these policies are lacking. We used data from the National Cancer Database 2003–2015 to conduct a quasi-experimental study of cancer patients ages 19–34 years, grouped as DCE-eligible (19- to 25-year-olds) and DCE-ineligible (27- to 34-year-olds). Although private insurance coverage in DCE-eligible cancer patients increased incrementally following DCE implementation (0.5 per quarter; P < .001), an immediate effect on Medicaid coverage gains was observed after ME in all young adult cancer patients (3.01 for DCE-eligible and 1.62 for DCE-ineligible, both P < .001). Therefore, DCE and ME each had statistically significant and distinct effects on insurance coverage gains. Distinct temporal patterns of ACA policies’ impact on insurance coverage gains likely affect patterns of receipt of cancer care. Temporal patterns should be considered when evaluating the impact of health policies.

Insurance Coverage, and Having a Regular Provider, and Utilization of Cancer Follow-up and Noncancer Health Care Among Childhood Cancer Survivors

The objective of this study was to assess the role of health insurance coverage on patterns of health care utilization and access to cancer-related follow-up and non-cancer care among childhood cancer survivors (CCS). Cross-sectional survey design was used. Childhood cancer survivors were from 2 large hospitals in Los Angeles County. In all, 235 were identified through the Los Angeles Cancer Surveillance Program, diagnosed between the ages of 5 and 18 in 2000-2007 with any cancer type except Hodgkin lymphoma. At data collection in 2009-2010, participants were between 15 and 25 years old. Study exposure was health insurance coverage (private, public, and uninsured). Main outcomes and measures were respondents' regular source of care for cancer follow-up, noncancer care, and both; and having a cancer follow-up visit, primary care visit, and hospital emergency department visit in the past 2 years. Compared with those with private insurance, the uninsured were less likely to have a regular source for cancer follow-up (odds ratio [OR] = 4.3, 95% confidence interval [CI] = 1.9-9.4), less likely to have a source for noncancer care (OR = 3.3, 95% CI 1.6-6.9), and less likely to have a source of care for both (OR = 5.3, 95% CI = 2.1-13.5). Furthermore, uninsured CCS were less likely to have made visits to cancer specialists (OR = 4.5, 95% CI = 2.1-9.50) and were less likely to have seen a primary care physician in the past 2 years (OR = 3.9, 95% CI = 1.8-8.2). In addition, those with public (vs private) insurance were less likely to have a regular provider for primary care (OR = 2.5, 95% CI = 1.1-5.4) and less likely to have made a primary care visit in the past year (OR = 2.8, 95% CI = 2.1-13.5). Uninsured CCS are at risk of not obtaining cancer follow-up care, and those with public (vs. private) insurance have less access to primary care. Policies that ensure continuity of coverage for survivors as they age into adulthood may result in fewer barriers to needed care, which may lead to fewer health problems for CCS in the future.

Increased clinical trial enrollment among adolescent and young adult cancer patients between 2006 and 2012-2013 in the United States

BACKGROUND

Stagnant outcomes for adolescents and young adults (AYAs) 15-39 years of age with cancer are partly attributed to poor enrollment onto clinical trials. Initiatives have focused on increasing accrual, but changes at the population-level are unknown. We examined patterns of clinical trial participation over time in AYA patients with cancer.

PROCEDURE

We utilized medical record data from AYAs in two population-based National Cancer Institute Patterns of Care Studies identified through the Surveillance, Epidemiology and End Results Program. Among 3135 AYAs diagnosed with non-Hodgkin lymphoma (NHL), Hodgkin lymphoma, acute lymphoblastic leukemia (ALL), and sarcoma, we used multivariate logistic regression to evaluate patient and provider characteristics associated with clinical trial enrollment. Interaction terms evaluated variation in clinical trial enrollment across patient and provider characteristics by year of diagnosis.

RESULTS

From 2006 to 2012-2013, clinical trial participation increased from 14.8% to 17.9% (P < 0.01). Adjusting for patient and provider characteristics, we found lower clinical trial enrollment among those who were older at diagnosis, diagnosed with NHL vs ALL, treated by adult hematologist/oncologists only (vs pediatric hematologist/oncologists), and of non-Hispanic Black race/ethnicity (vs non-Hispanic White) (P < 0.05 for all). Interaction analyses indicate improved clinical trial enrollment from 2006 to 2012-2013 among young adults 25-29 years of age and the uninsured.

CONCLUSIONS

Although disparities in enrollment onto clinical trials remain for AYAs with cancer, our study identified increasing overall clinical trial participation over time. Further, we identify promising trends in enrollment uptake among AYAs 25-29 years of age and the uninsured.

"It still affects our economic situation": long-term economic burden of breast cancer and lymphedema

PURPOSE

Financial toxicity after breast cancer may be exacerbated by adverse treatment effects, like breast cancer-related lymphedema. As the first study of long-term out-of-pocket costs for breast cancer survivors in the USA with lymphedema, this mixed methods study compares out-of-pocket costs for breast cancer survivors with and without lymphedema.

METHODS

In 2015, 129 breast cancer survivors from Pennsylvania and New Jersey completed surveys on demographics, economically burdensome events since cancer diagnosis, cancer treatment factors, insurance, and comorbidities; and prospective monthly out-of-pocket cost diaries over 12 months. Forty participants completed in-person semi-structured interviews. GLM regression predicted annual dollar amount estimates.

RESULTS

46.5% of participants had lymphedema. Mean age was 63 years (SD = 8). Average time since cancer diagnosis was 12 years (SD = 5). Over 98% had insurance. Annual adjusted health-related out-of-pocket costs excluding productivity losses totaled $2306 compared to $1090 (p = 0.006) for those without lymphedema, or including productivity losses, $3325 compared to $2792 (p = 0.55). Interviews suggested that the cascading nature of economic burden on long-term savings and work opportunities, and insufficiency of insurance to cover lymphedema-related needs drove cost differences. Higher costs delayed retirement, reduced employment, and increased inability to access lymphedema care.

CONCLUSIONS

Long-term cancer survivors with lymphedema may face up to 112% higher out-of-pocket costs than those without lymphedema, which influences lymphedema management, and has lasting impact on savings and productivity. Findings reinforce the need for actions at policy, provider, and individual patient levels, to reduce lymphedema costs. Future work should explore patient-driven recommendations to reduce economic burden after cancer.

Adolescent angst: enrollment on clinical trials

Survival among adolescents and young adults (AYAs) ages 15 to 39 with cancer has not improved to the same extent as that of pediatric and older adult cancer patients, which is thought to relate, in part, to the lower participation of AYAs in clinical trials. Because significant efforts have been made to improve clinical trial enrollment for AYAs, we (1) present contemporary clinical trial enrollment rates by cancer type, sociodemographic characteristics, and treatment setting and (2) discuss provider-, patient-, and system-level barriers to clinical trial participation. Contemporary studies examining clinical trial enrollment among AYAs have continued to find low overall participation relative to pediatric populations, with most studies observing no significant improvements in enrollment over time. In addition to age and cancer type, enrollment varies by treatment setting, health insurance, and race/ethnicity. Access to available clinical trials may be increased by appropriate referral of AYAs to pediatric and adult specialty cancer centers with studies relevant to the AYA population because most AYAs are treated in the community setting. Even with similar access to trials, however, AYAs may be less likely to participate, and therefore, future efforts should focus on better understanding and addressing barriers to enrollment as well as improving education and outreach regarding clinical trials.

The impact of dependent coverage expansion under the Affordable Care Act on time to breast cancer treatment among young women

INTRODUCTION

Breast cancer in young women tends to be more aggressive, but timely treatment may not be always available, particularly to those without health insurance. We aim to examine whether the dependent coverage expansion under the Affordable Care Act (ACA-DCE) implemented in 2010 was associated with changes in time to treatment among women diagnosed with early stage breast cancer.

METHODS

A total of 7,176 patients diagnosed with early stage breast cancer in 2007-2009 (pre-ACA) and 2011-2013 (post-ACA) were identified from the National Cancer Database. A quasi-experimental design difference-in-differences (DD) approach was used, with patients aged 19-25 (targeted by the policy) considered as the intervention group, and patients aged 26-34 years (not affected by the policy) as the control group. Changes in the following treatment outcomes were examined: time from diagnosis to surgery, time from surgery to adjuvant chemotherapy, and time from adjuvant chemotherapy to radiation.

RESULTS

Compared with the control group of patients aged 26-34, young patients aged 19-25 experienced a statistically nonsignificant decrease of 2.7 percentage points (95% CI [-1.2, 6.5]) in the uninsured rate. This did not translate into more reduction in delays to surgery (DD = 2.7 days, 95% CI [-3.2, 8.3]), chemotherapy (DD = -1.0 days, 95% CI [-7.2, 5.2]) or radiation (DD = 5.3 days, 95% CI [-15.6, 26.3]) in the younger cohort than the older cohort.

CONCLUSIONS AND RELEVANCE

No significant changes in time to treatment were found among young women diagnosed with early stage breast cancer after the implementation of the ACA-DCE. Future studies examining impacts of health care policy reform on breast cancer care are warranted to include patients from low-income families and to consider effects from Medicaid expansion.

Patient Protection and Affordable Care Act Medicaid expansion and gains in health insurance coverage and access among cancer survivors

BACKGROUND

The Patient Protection and Affordable Care Act extends Medicaid coverage to millions of low-income adults, including many survivors of cancer who were unable to purchase affordable health insurance coverage in the individual health insurance market.

METHODS

Using data from the 2011 to 2015 Behavioral Risk Factor Surveillance System, the authors compared changes in coverage and health care access measures for low-income cancer survivors in states that did and did not expand Medicaid.

RESULTS

The study population of 17,381 individuals included adults aged 18 to 64 years, and was predominantly female, white, and unmarried. The authors found a relative reduction in the uninsured rate of 11.7 percentage points and a relative increase in the probability of having a personal physician of 5.8 percentage points. Stratifying by whether states expanded Medicaid by 2015, the authors found that relative gains in coverage and access were larger among those individuals residing in states with expanded Medicaid compared with those residing in nonexpansion states.

CONCLUSIONS

The results of the current study suggest that the Patient Protection and Affordable Care Act Medicaid expansion has improved coverage and access for cancer survivors. Cancer 2018;124:2645-52. © 2018 American Cancer Society.

A New Lease on Life: Preliminary Needs Assessment for the Development of a Survivorship Program for Young Adult Survivors of Cancer in South Texas

Priorities for young adult survivorship care from the survivors' perspective are not well documented. To address this within our patient population, we conducted a multimethod needs assessment of young adult survivors of pediatric, adolescent, and young adult cancer in South Texas to get a better understanding of the ongoing challenges and priorities for their survivorship needs and related services. Participants were 18 to 39 years at the time of the needs assessment and predominately Hispanic. In an online survey, survivors most commonly cited being concerned about their physical and mental health, long-term treatment effects, recurrence, and health insurance issues. Participants stated that they received critical support from family, friends, and medical staff, but they would like to receive additional support from other cancer survivors through peer mentorship opportunities and survivor retreats/social events.

Changes in Health Insurance Coverage Associated With the Affordable Care Act Among Adults With and Without a Cancer History: Population-based National Estimates

BACKGROUND

The Affordable Care Act (ACA) improved health care coverage accessibility by expanding Medicaid eligibility, creating insurance Marketplaces, and subsidizing premiums. We examine coverage changes associated with ACA implementation, comparing adults with and without a cancer history.

METHODS

We included nonelderly adults from the 2012 to 2015 National Health Interview Survey. Using information on state Medicaid policies (2013), expansion decisions (2015), family structure, income, insurance offers, and current coverage, we assigned adults in all 4 years to mutually exclusive eligibility categories including: Medicaid-eligible pre-ACA; expansion eligible for Medicaid; and Marketplace premium subsidy eligible. Linear probability regressions estimated pre-post (2012-2013 vs. 2014-2015) coverage changes by eligibility category, stratified by cancer history.

RESULTS

The uninsured rate for cancer survivors decreased from 12.4% to 7.7% (P<0.001) pre-post ACA implementation. Relative to income >400% of the federal poverty guideline, the uninsured rate for cancer survivors decreased by an adjusted 8.4 percentage points [95% confidence interval (CI), 1.3-15.6] among pre-ACA Medicaid eligible; 16.7 percentage points (95% CI, 9.0-24.5) among expansion eligible, and 11.3 percentage points (95% CI, -0.8 to 23.5, with a trend P=0.069) for premium subsidy eligible. Decreases in uninsured among expansion-eligible adults without a cancer history [9.7 percentage points (95% CI, 7.4-12.0), were smaller than for cancer survivors (with a trend, P=0.086)]. Despite coverage gains, ∼528,000 cancer survivors and 19.1 million without a cancer history remained uninsured post-ACA, yet over half were eligible for Medicaid or subsidized Marketplace coverage.

CONCLUSIONS

ACA implementation was associated with large coverage gains in targeted expansion groups, including cancer survivors, but additional progress is needed.

Coming of Age With Cancer: Physical, Social, and Financial Barriers to Independence Among Emerging Adult Survivors

PURPOSE

To explore the transition to self-care among a sample of emerging adult cancer survivors after hematopoietic cell transplantation (HCT). 
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PARTICIPANTS & SETTING

18 HCT survivors who were aged 18-29 years at the time of HCT for a primary hematologic malignancy and were 8-60 months post-HCT participated in the study. The study took place in the hematology outpatient setting at City of Hope National Medical Center.
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METHODOLOGIC APPROACH

The authors conducted in-depth semistructured interviews and analyzed interview transcripts using grounded theory methodology.
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FINDINGS

Health-related setbacks following HCT disrupted not only participants' journey toward self-care, but also their overarching developmental trajectory toward adulthood. Physically, participants struggled with lack of personal space around caregivers, but felt unready to live on their own. Socially, they relied on multiple caregivers to avoid relying too much on any one person. Financially, participants worried about prolonged dependence and increased needs in the future.
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IMPLICATIONS FOR NURSING

Nurses can support the transition to self-care among emerging adults after HCT by recognizing the broader developmental impact of their cancer experience.

Survivorship Issues in Adolescent and Young Adult Oncology

Adolescent and young adult (AYA) individuals with a history of cancer make up a fraction of the total number of cancer survivors in the United States, but they represent a population with needs distinct from either the childhood or the older adult cancer populations. Fertility concerns, psychosocial factors, and health care access are just a few of the distinguishing characteristics. Caring for AYA cancer survivors presents unique opportunities for primary care providers to collaborate with oncology colleagues to minimize the long-term cancer burden.

Impact of insurance status on the survival of gallbladder cancer patients

The prognostic significance of insurance status has been investigated in many types of malignancies, however, its impact on gallbladder cancer is yet not known. The purpose of this study was to determine the relationship between insurance status and gallbladder cancer survival. We searched the Surveillance, Epidemiology, and End Results dataset, and identified 1,729 gallbladder cancer cases. Kaplan-Meier methods and multivariable Cox regression models were used to analyze survival outcomes and risk factors. We found that individuals who had non-Medicaid insurance were more likely to be male, older, from wealthier area, and better-educated. Insurance status was confirmed as an independent prognostic factor for gallbladder cancer patients. Stratified analysis revealed that the uninsured status independently predicted unfavorable survival outcome at localized tumor stage and in white individuals. To conclude, insurance status is an important predictive factor for gallbladder cancer, and uninsured individuals are at the highest risk of death.

The effect of the affordable care act dependent coverage provision on patients with cystic fibrosis

BACKGROUND

The Patient Protection and Affordable Care Act (ACA), enacted in 2010, expanded private insurance coverage of young adults through the dependent coverage provision. This policy's implications for patients with cystic fibrosis (CF) are unknown.

METHODS

The CF Foundation Patient Registry was used to identify patients seen at CF centers, 3 years before and after ACA implementation. Patients were grouped according to eligibility for the dependent care provision (18-25 years old in 2010) or ineligibility (26-35 years old). Year-level difference-in-difference logistic regressions evaluated the association between ACA enactment and insurance status (private, public, or no insurance). Routine annual care consistent with CF Foundation guidelines (≥4 clinic visits, ≥4 respiratory cultures, and ≥2 pulmonary function tests/year) was a secondary outcome.

RESULTS

The analysis included 4,024 and 3,132 patients in the eligible and ineligible groups, respectively (35,353 patient-years). In the eligible group, 62% had private insurance before and after ACA; 18% had public insurance before and after ACA; and 5% switched from public to private insurance. In the eligible group, lack of insurance coverage became more common in the post-ACA period (relative risk ratio vs. private insurance [RRR] = 1.95; 95%CI: 1.57, 2.43; P < 0.001). Public insurance coverage also became more common (RRR = 1.50; 95%CI: 1.39, 1.62; P < 0.001). Use of routine care increased post-ACA, but more strongly in the ineligible group than in the eligible group.

CONCLUSIONS

The ACA dependent coverage provision did not increase private insurance coverage or use of routine care among CF patients who were potentially affected by this policy. Pediatr Pulmonol. 2017;52:458-466. © 2017 Wiley Periodicals, Inc.