A fundamental question in health reform is how changes to insurance policy affect health insurance coverage. Since the passage of the Affordable Care Act (ACA) in 2010, research has demonstrated that the ACA reduced the uninsured rate across the country [pdf]. By expanding eligibility for the Medicaid program, establishing marketplaces for the purchase of private insurance, providing subsidies to make insurance more affordable, and prohibiting denials based on pre-existing conditions, the law helped millions of individuals gain access to health insurance.
One of the key features of the ACA was its emphasis on preventive services. For all adults, it mandated that many insurance plans and all plans sold on the Marketplace cover cancer screening for applicable populations without a copay (or any cost-sharing) when provided in-network. Recent work has shown that this coverage has translated into increased screenings and services for some populations.
The expansion of health insurance under the ACA is also crucial at the other end of the care spectrum, such as for people who have survived cancer. For people ineligible for Medicare who have already incurred the financial stress of initial treatment, obtaining and maintaining either Medicaid or private insurance throughout this later treatment phase is important to control cancer recurrence, improve quality of life, and decrease mortality. Under ACA, many adults who survived cancer were newly eligible for insurance via Medicaid or premium subsidies, resulting in increases in coverage for many cancer survivors in Medicaid expansion states. Evidence suggests that insurance such Medicaid increases individuals’ use of primary and preventive care, while also improving regular access to physicians and increasing the number of physician visits in a year, all components of health care utilization that can help prevent cancer recurrence. Survivorship care has been understudied, so more needs to be done to understand the role of insurance in survivorship care.
A new study in Medical Care by Davidoff and colleagues beings to fill that gap by estimating how much insurance coverage changed among cancer survivors before and after the ACA.
Using data from the National Health Interview Survey (NHIS), the authors estimated changes across many different insurance eligibility categories, splitting their analyses between individuals with cancer history and those without. They found substantial decreases in the uninsured rate among those with cancer history post-ACA. The population eligible for Medicaid before the ACA saw an 8.4 percentage point decrease in the uninsured rate; the Medicaid expansion eligible population after the ACA saw a 16.7 percentage point decrease, and the population eligible for premium subsidies saw an 11.3 percentage point decrease. Interestingly, but perhaps not surprisingly, the decline in the uninsured rate was larger for cancer survivors than those without a cancer history.
Despite these gains, the authors are cautiously optimistic about the results. As they note, there were some marked differences between adult cancer survivors and those without a cancer history, the former being older, less likely to have dependents, and wealthier; these underlying differences complicate interpretations of causality. Perhaps more importantly, they note that more than 500,000 cancer survivors across the United States still lacked health insurance coverage, suggesting that more should be done to address this population, despite the progress already made.
One aspect that remains an open question is: what happens after receipt of coverage? Does consistent insurance coverage actually help prevent cancer recurrence? A useful case study for these questions may be found in breast cancer patients.
Breast cancers are one of the most commonly diagnosed cancers. Women with estrogen-receptor positive cancers (approximately 75%-80% of all cancer diagnoses) are frequently required to adhere to a drug regimen of adjuvant hormone therapies (AHTs) after chemotherapy that reduces cancer risk. Nonadherence to AHTs is associated with cancer recurrence, poor treatment outcomes, and limited effectiveness of the drugs. However, not all patients are at equal risk for nonadherence. Those who regularly see a physician or have an oncologist visit, or those who have lower out-of-pocket costs, are more likely to adhere to their drug regimen and see better outcomes. To that end, health insurance may serve as an essential vehicle for improving AHT adherence among breast cancer survivors; theoretically, it should help mitigate the costs and challenges of obtaining the drugs or seeing a doctor. Empirical evidence on this specific case could offer broader implications about the implications of being uninsured as a cancer survivor.
This new paper underscores the gains made in health coverage among cancer survivors, shedding important light on cancer survivorship, an understudied subject in policy research. Importantly, however, it also highlights the considerable progress needed – both in policy and research – to further understand how health insurance can impact the lives of those with a cancer history.
Thanks to Graeme Petersen who helped prepare this post.
Ben Allaire