The Patient Protection and Affordable Care Act dependent coverage expansion: Disparities in impact among young adult oncology patients

Abstract

BACKGROUND Private health insurance is associated with improved outcomes in patients with cancer. However, to the authors' knowledge, little is known regarding the impact of the Patient Protection and Affordable Care Act Dependent Coverage Expansion (ACA‐DCE), which extended private insurance to young adults (to age 26 years) beginning in 2010, on the insurance status of young adults with cancer. METHODS The current study was a retrospective, population‐based analysis of hospitalized young adult oncology patients (aged 22‐30 years) in California during 2006 through 2014 (11,062 patients). Multivariable regression analyses examined factors associated with having private insurance. Results were presented as adjusted odds ratios and 95% confidence intervals. A difference‐in‐difference analysis examined the influence of the ACA‐DCE on insurance coverage by race/ethnicity and federal poverty level. RESULTS Multivariable regression demonstrated that patients of black and Hispanic race/ethnicity were less likely to have private insurance before and after the ACA‐DCE, compared with white patients. Younger age (22‐25 years) was associated with having private insurance after implementation of the ACA‐DCE (odds ratio, 1.20; 95% confidence interval, 1.06‐1.35). In the difference‐in‐difference analysis, private insurance increased among white patients aged 22 to 25 years who were living in medium‐income (2006‐2009: 64.6% vs 2011‐2014: 69.1%; P = .003) and high‐income (80.4% vs 82%; P = .043) zip codes and among Asians aged 22 to 25 years living in high‐income zip codes (73.2 vs 85.7%; P = .022). Private insurance decreased for all Hispanic patients aged 22 to 25 years between the 2 time periods. CONCLUSIONS The ACA‐DCE provision increased insurance coverage, but not among all patients. Private insurance increased for white and Asian patients in higher income neighborhoods, potentially widening social disparities in private insurance coverage among young adults with cancer. Cancer 2018;124:110‐7. © 2017 American Cancer Society.

Adolescent and young adult oncology—past, present, and future

“…These changes reduced the number of uninsured AYA patients by 50% in the first 4 years of the ACA, with the dependent care expansion significantly increasing private insurance coverage among those aged 19 to 25 years and the Medicaid expansion increasing public insurance coverage for all young adults . This coverage, however, has not extended equally to all socioeconomic and racial groups, especially AYA patients with low socioeconomic status (SES) or who are black and/or Hispanic and are less likely to have insurance coverage even after the ACA, especially in states that did not expand Medicaid eligibility …”

“…Since the implementation of the ACA starting in 2010, there is evidence that the dependent coverage expansion, marketplace insurance, insurance subsidies, and Medicaid expansions have improved insurance coverage and access to care for AYA patients . However, many AYA patients continue to be uninsured or underinsured, and research supports that these individuals may have worse outcomes . The addition of health insurance alone does not address all socioeconomic concerns that AYA patients face, and future efforts should focus not only on identifying disparities but also on interventions to help improve care for all patients.…”

“…43,47,48 This coverage, however, has not extended equally to all socioeconomic and racial groups, es pecially AYA patients with low socioeconomic status (SES) or who are black and/or Hispanic and are less likely to have insurance coverage even after the ACA, especially in states that did not expand Medicaid eligibility. 6,49,50 In addition to being underinsured or uninsured, other so cioeconomic concerns are a universal consideration for AYA patients, although specific concerns differ based on their age and the presence of dependents. 51 There is evidence sup porting a relationship between poverty and decreased access to health care, poorer health care utilization, and inferior patient outcomes in multiple medical conditions, including cancer.…”

“…There are many unique aspects of care to consider in this population that may influence outcomes both during and after therapy. These include developmental status of the age group, research focus of age‐based cooperative groups, socioeconomic impact of health insurance and access to care, and biologic differences in cancer types . Many of these issues are unique to the AYA population, which may complicate medical care and require additional support compared with either older adults or younger children.…”

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

“…Among AYAs with cancer, a Surveillance, Epidemiology, and End Results‐based study documented that 83.5% of 18–25 year olds had health insurance before the ACA, which increased to 85.4% after implementation of the ACA, although the insured rate actually dropped from 83.4% to 82.9% among those aged 26–29 years . Even within California, among AYAs with cancer aged 22–29 years improved insurance coverage post ACA was greatest among Whites and Asians in high‐income neighborhoods …”