Association Between the Affordable Care Act Dependent Coverage Expansion and Cervical Cancer Stage and Treatment in Young Women

On September 23, 2010, the Affordable Care Act Dependent Coverage Expansion (ACA-DCE) went into effect, allowing young adults to remain on their parents’ health insurance plans until age 26 years. Implementation of the ACA-DCE was followed by a net increase in private health insurance coverage among young adults aged 19 to 25 years.¹ Persons without private health insurance are less likely to be screened and more likely to be diagnosed at an advanced stage of cancer.²

For young adults, the uterine cervix is the only cancer site for which screening is recommended. Since November 2009, the American College of Obstetricians and Gynecologists has recommended cervical cancer screening begin at age 21 years. Diagnosis of cervical cancer at early stages also allows use of fertility-sparing treatments. Using data before and after the ACA-DCE, we compared changes in cervical cancer stage at diagnosis and initial treatment among young women aged 21 to 25 years (DCE-eligible) and 26 to 34 years (non–DCE-eligible).

The National Cancer Data Base, a national hospital-based cancer registry, was used to obtain data on cases of invasive cervical cancer, with stage at diagnosis classified as early (stages I/II) or late (stages III/IV).³ The database documents approximately 70% of all malignant cancers in the United States annually.⁴ We selected all women aged 21 to 34 years with a first primary invasive cervical cancer. The deidentified study was waived from institutional review board approval by the Morehouse School of Medicine.

The associations between insurance (categorized as private, uninsured, Medicaid, or other/unknown) and diagnosis of early-stage disease and receipt of fertility-sparing treatments were examined. We also examined stage at cancer diagnosis and initial treatment of cervical cancer across 2 periods (before ACA-DCE, January 2007-December 2009; after ACA-DCE, January 2011-December 2012). The year 2010 was treated as a washout or phase-in period and was excluded. We used a pre-post design and conducted a difference-in-differences analysis, in which young women aged 21 to 25 years were the treatment group and those aged 26 to 34 years were controls.

Both unadjusted and adjusted linear probability models were fitted, controlling for single years of age, race/ethnicity, and area-level education and income. Temporal trends in proportions of early-stage disease and fertility-sparing treatment by DCE eligibility were plotted using an arithmetic scale. Version 9.4 of SAS (SAS Institute Inc) was used for the statistical analyses. All statistical testing was 2-sided at a significance level of .05.

We identified 3937 cervical cancer cases diagnosed pre-DCE and 2480 cases post-DCE. Patients with private insurance were more likely than those with Medicaid or uninsured to be diagnosed with early-stage disease (77.8% [2753/3540] with private insurance vs 64.7% [1265/1954] with Medicaid and 67.0% [409/610] uninsured; P < .001) and more likely to receive fertility-sparing treatments (23.6% [837/3540] with private insurance vs 12.2% [239/1954] with Medicaid and 16.7% [102/610] uninsured; P < .001).

Between the pre- and post-DCE periods, compared with 26- to 34-year-olds, women aged 21 to 25 years experienced a net increase of 9.0 (95% CI, 2.0-16.2) percentage points in early-stage disease (P = .01) and 11.9 (95% CI, 4.3-19.5) percentage points in receipt of fertility-sparing treatments (P = .002). Both results remained statistically significant in multivariable models (Table).

Among women aged 21 to 25 years, the proportion of early-stage disease increased from 67.9% in 2009 to 84.3% in 2011 and decreased to 72.3% in 2012; the proportion receiving fertility-sparing treatment increased throughout the study period (Figure).

Although based on early data (2 years after the ACA-DCE), these findings suggest an association between the ACA-DCE provision and cervical cancer stage at diagnosis and receipt of fertility-sparing treatment among young women aged 21 to 25 years, but not among women aged 26 to 34 years. However, the increase in proportion of early-stage disease in 2011 followed by a decrease in 2012 may reflect detection of prevalent early-stage disease associated with increased access to care or random fluctuation. The increase in rates of fertility-spring treatment after the ACA may reflect continuation of a pre-ACA trend.

Our study is limited by its ecological design. Future work should continue to monitor cancer care and outcomes in populations targeted by the ACA.

Corresponding Author: Xuesong Han, PhD, Surveillance and Health Services Research, American Cancer Society, 250 Williams St NW, Atlanta, GA 30303 (xuesong.han@cancer.org).

Author Contributions: Dr Han had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Robbins, Jemal.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Robbins, Han.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Robbins, Han.

Administrative, technical, or material support: Robbins, Han, Ward, Jemal.

Study supervision: Ward, Jemal.

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Funding/Support: This work was supported by the Intramural Research Department of the American Cancer Society.

Role of the Funder/Sponsor: The American Cancer Society had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The opinions expressed are solely the responsibility of the authors and do not necessarily reflect the official views of the American Cancer Society.