Association of the Patient Protection and Affordable Care Act With Insurance Coverage for Head and Neck Cancer in the SEER Database | Head and Neck Cancer | JAMA Otolaryngology–Head & Neck Surgery | JAMA Network
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Original Investigation
From the American Head and Neck Society
November 2018

Association of the Patient Protection and Affordable Care Act With Insurance Coverage for Head and Neck Cancer in the SEER Database

Author Affiliations
  • 1Division of Otolaryngology–Head and Neck Surgery, School of Medicine, University of Utah, Salt Lake City
  • 2Department of Otolaryngology–Head and Neck Surgery, School of Medicine, University of Washington, Seattle
JAMA Otolaryngol Head Neck Surg. 2018;144(11):1052-1057. doi:10.1001/jamaoto.2018.1792
Key Points

Question  What is the association of the Patient Protection and Affordable Care Act with rates of insurance coverage and access to care among patients with head and neck squamous cell cancer?

Findings  This population-based study used prospectively gathered data from the Surveillance, Epidemiology, and End Results database and found an increase in the percentage of patients enrolled in Medicaid and private insurance and a large decrease in the rates of uninsured patients after implementation of the Patient Protection and Affordable Care Act in states that adopted the Medicaid expansion in 2014. Patients who were uninsured prior to the Patient Protection and Affordable Care Act had poorer survival outcomes.

Meaning  With the implementation of the Patient Protection and Affordable Care Act, there has been a substantial reduction in uninsured patients and improved access to health care among patients with head and neck squamous cell cancer.

Abstract

Importance  Patients with head and neck squamous cell cancer (HNSCC) are often uninsured or underinsured at the time of their diagnosis. This access to care has been shown to influence treatment decisions and survival outcomes.

Objective  To examine the association of the Patient Protection and Affordable Care Act (ACA) health care legislation with rates of insurance coverage and access to care among patients with HNSCC.

Design, Setting, and Participants  Prospectively gathered data from the Surveillance, Epidemiology, and End Results (SEER) database were used to examine rates of insurance coverage and access to care among 89 038 patients with newly diagnosed HNSCC from January 2007 to December 2014. Rates of insurance were compared between states that elected to expand Medicaid coverage in 2014 and states that opted out of the expansion. Statistical analysis was performed from January 1, 2007, to December 31, 2014.

Main Outcomes and Measures  Rates of insurance coverage and disease-specific and overall survival.

Results  Among 89 038 patients newly diagnosed with HNSCC (29 384 women and 59 654 men; mean [SD] age, 59.8 [7.6] years), there was an increase after implementation of the ACA in the percentage of patients enrolled in Medicaid (16.2% after vs 14.8% before; difference, 1.4%; 95% CI, 1.1%-1.7%) and private insurance (80.7% after vs 78.9% before; difference, 1.8%; 95% CI, 1.2%-2.4%). In addition, there was a large decrease in the rate of uninsured patients after implementation of the ACA (3.0% after vs 6.2% before; difference, 3.2%; 95% CI, 2.9%-3.5%). This decrease in the rate of uninsured patients and the associated increases in Medicaid and private insurance coverage were only different in the states that adopted the Medicaid expansion in 2014. No survival data are available after implementation of the ACA, but prior to that point, from 2007 to 2013, uninsured patients had reduced 5-year overall survival (48.5% vs 62.5%; difference, 14.0%; 95% CI, 12.8%-15.2%) and 5-year disease-specific survival compared with insured patients (56.6% vs 72.2%; difference, 15.6%; 95% CI, 14.0%-17.2%).

Conclusions and Relevance  Access to health care for patients with HNSCC was improved after implementation of the ACA, with an increase in rates of both Medicaid and private insurance and a 2-fold decrease in the rate of uninsured patients. These outcomes were demonstrated only in states that adopted the Medicaid expansion in 2014. Uninsured patients had poorer survival outcomes.

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