Socioeconomic and Demographic Variation in Insurance Coverage Among Patients With Head and Neck Cancer After the Affordable Care Act | Head and Neck Cancer | JAMA Otolaryngology–Head & Neck Surgery | JAMA Network
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Figure.  Changes in the Percentage of Uninsured Patients With Head and Neck Cancer After the Implementation of the Patient Protection and Affordable Care Act (ACA)
Changes in the Percentage of Uninsured Patients With Head and Neck Cancer After the Implementation of the Patient Protection and Affordable Care Act (ACA)

A, Changes in the percentage of uninsured patients with head and neck cancer after the ACA by age. B, Changes in the percentage of uninsured patients with head and neck cancer after the ACA by county income.

Table 1.  Descriptive Statistics of the Study Population
Descriptive Statistics of the Study Population
Table 2.  Pre- and Post-ACA Changes in the Percentage of Uninsured Patients With Head and Neck Cancer
Pre- and Post-ACA Changes in the Percentage of Uninsured Patients With Head and Neck Cancer
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    Original Investigation
    October 31, 2019

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

    Author Affiliations
    • 1Duke University School of Medicine, Durham, North Carolina
    • 2St Louis University School of Medicine, St Louis, Missouri
    • 3Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts
    • 4Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
    JAMA Otolaryngol Head Neck Surg. 2019;145(12):1144-1149. doi:10.1001/jamaoto.2019.2724
    Key Points

    Question  How does the association between implementation of the Patient Protection and Affordable Care Act (ACA) and change in insurance status vary across sociodemographic subpopulations of patients with head and neck cancer (HNC)?

    Findings  In this cohort study of 131 779 patients from the National Cancer Database, patients with HNC experienced a significant reduction in uninsured rates after implementation of the ACA. Young adults and patients from low-income zip codes experienced greater increases in coverage than those from older age groups and higher-income zip codes.

    Meaning  Implementation of the ACA was associated with greater insurance coverage among populations of patients with HNC with historically limited access to care.

    Abstract

    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.

    Introduction

    Globally, more than 600 000 cases of head and neck cancer (HNC) are diagnosed every year.1 In the United States, approximately 63 000 people are diagnosed with HNC each year and more than 13 000 die of disease-specific causes.2 Insurance status is among the factors significantly associated with outcomes in patients with HNC. Patients with HNC without insurance have poorer survival outcomes and present at more advanced stages of disease compared with those who are insured.3-5

    The Patient Protection and Affordable Care Act (ACA) has expanded insurance coverage in the United States, considerably increasing access to care for millions of people.6-9 For patients with cancer, there is evidence that the ACA is associated with increases in insurance coverage and access to care.3 Disparities in insurance uptake post-ACA among the overall population of patients with cancer have been examined in prior studies.10,11 In 2018, Han et al12 showed a significant decrease in the percentage of uninsured patients with cancer in almost all states in addition to a narrowing of health disparities by race/ethnicity, poverty level, and rurality across Medicaid expansion states. Among patients with HNC in particular, changes in insurance status in the ACA era have been examined to a lesser extent, with data showing an overall decrease in the uninsured population after ACA implementation.13 Yet, our understanding of the impact on coverage among patients with HNC, particularly with regard to variation across different socioeconomic and demographic groups, remains limited.

    Examining potential disparities in insurance rates after ACA coverage expansions may inform future policy and community-level interventions to increase equity in access to care. We hypothesize that the ACA is associated with both overall increases in coverage for patients with HNC, as well as significantly greater increases in coverage for populations with historically limited ability to access insurance benefits. The objective of this study is to assess changes in insurance coverage across socioeconomic and demographic subgroups of patients with HNC before and after implementation of the ACA.

    Methods

    The National Cancer Database (NCDB) was queried for adults aged 18 to 74 years diagnosed with a first primary head and neck malignant abnormality between 2011 and 2015. The NCDB is a nationwide hospital-based cancer database containing 70% of all newly diagnosed cancers in the United States. The NCDB is the result of a collaboration between the Commission on Cancer (CoC), the American Cancer Society and the American College of Surgeons.14 Both the NCDB and the hospitals represented through the NCDB are not responsible for the statistical analyses or inferences presented in this study. Cases with missing insurance information or missing or unspecified covariates (race, sex, rural/urban residence status, and county-level income and education, and cancer type) were excluded. Cases from facilities not reporting cancer diagnoses in all years were also excluded. Descriptions of all variables used in our analyses can be found in the NCDB data dictionary.14 This study was determined to be exempt from review and patient informed consent by the institutional review boards of the Massachusetts Eye and Ear Infirmary and Saint Louis University School of Medicine because all data used were deidentified.

    The outcome variable was uninsured status at the time of cancer diagnosis, which has been associated with poorer prognosis in patients with HNC.3-5 Zip code was used as proxy for income level through correlation with household income quartiles, which were derived from United States Census data from the year 2000. The zip code categories used were less than $30 000, $30 000 to $34 999, $36 000 to $45 999, and $46 000 or more. Race/ethnicity was categorized as non-Hispanic white, non-Hispanic black, Hispanic, and non-Hispanic other. Sex was categorized as male or female.

    We used linear probability regression models with robust standard errors to evaluate changes in the percentage of uninsured patients from 2011 to 2013 (pre-ACA) to 2014 to 2015 (post-ACA). To account for potential confounding, the regression models included covariates adjusting for age, race, sex, rural/urban residence status, county-level income and education, and cancer site. We performed analyses for all sites, stratified by cancer site, and stratified by socioeconomic and demographic factors. To formally compare differences in changes in the percent uninsured between socioeconomic and demographic factors, we expanded the regression models to include an interaction variable between the time period (pre- or post-ACA implementation) and the demographic/socioeconomic factor of interest. Analyses were performed using R statistical software (version 3.3.2, R Foundation), and were performed from November, 2018 through December, 2018.

    Results

    After exclusions, 77 071 and 54 708 patients with HNC were identified in the pre- and post-ACA periods, respectively. Most of the cohort was non-Hispanic white (106 151 [80.6%]), male (98 207 [74.5%]), aged between 50 and 64 years (73 124 [55.5%]), and resided in metropolitan areas (108 140 [82.1%]).

    There was a relatively even distribution of patients across the low (26 647 [20.2%]), mid-low (32 352 [24.6%]), mid-high (34 950 [26.5%]), and high (37 830 [28.7%]) income categories. Population characteristics were stable between the pre- and post-ACA periods (Table 1).

    The percentage of patients with HNC without insurance dropped from 7.7% in the pre-ACA period to the 4.9% post-ACA period, a 2.68 percentage point decrease (PPD) (95% CI, 2.93-2.42). Net decreases were observed across all subgroups, and significant reductions were observed for most subpopulations (Table 2). There was a significant difference in the changes in the percentage of uninsured patients by age, with the largest reduction in uninsured 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) as depicted in the Figure, part A. There were also significantly different changes in lack of insurance by sex, with larger reductions in women (3.19 PPD; 95% CI, 2.72-3.67) than in men (2.50 PPD; 95% CI, 2.19-2.80). Furthermore, there was a significantly greater reduction in the percentage of uninsured patients in low-income zip codes (3.45 PPD; 95% CI, 2.76-4.14) after ACA implementation than in high-income zip codes (1.99 PPD; 95% CI, 1.63-2.36) (Figure, B). There was no significant heterogeneity among changes in uninsured status after ACA implementation by cancer site, race, metropolitan residence, or zip code education.

    Discussion

    Health insurance status is a major determinant of quality of care and outcomes for patients with cancer. The objective of this study was to examine the association between implementation of the ACA and insurance status across socioeconomic and demographic subpopulations of patients with HNC. The period after implementation of the ACA was associated with a decrease in percentage of uninsured patients with HNC overall. Prior studies show that this trend is consistent with that seen both in the overall cancer population as well as in other types of cancer, suggesting an increase in access to health services for many patients with cancer nationwide.12,13,15 Of note, there was a larger reduction in the uninsured rate among patients from low-income zip codes compared with those from high-income zip codes. Reductions in uninsured status were most pronounced in younger adults, with the largest reduction seen in patients aged 18 to 34 years and the smallest reduction seen in patients aged 65 to 74 years. Our findings provide new insight into how insurance coverage after implementation of the ACA varies across socioeconomic subgroups of the HNC population.

    Our study found a larger reduction in uninsured rate among patients with HNC from low-income zip codes compared with those from high-income zip codes. Many of the policy changes implemented by the ACA were intended to benefit patient populations with lower income levels. Through the ACA provisions enacted in 2014, states were authorized to extend full Medicaid eligibility to residents who had annual incomes below 138% of the federal poverty level.16 The ACA also provided access to health insurance marketplaces, which facilitated the purchase of standardized insurance plans. For consumers with an annual income between 138% to 400% of the federal poverty level, coverage through the health exchange was subsidized. The Marketplace also extended coverage to patients with preexisting conditions, who may not have had coverage before the implementation of the ACA owing to prohibitive insurance costs.16

    Prior studies have demonstrated the impact of the ACA on increased coverage in states that adopted the Medicaid expansion provision, showing greater access for low-income populations.12,17 Specifically examining the effects on patients with HNC, Cannon et al13 found a similar decrease in the overall rate of uninsured patients with HNC in addition to an increase in the rates of both Medicaid and private insurance enrollment in Medicaid-expansion states. However, to date, no studies have examined post-ACA insurance coverage changes among patients with HNC using zip code or area of residence as a proxy for income level, to our knowledge. Head and neck cancer is one of the costliest cancers to treat, and patients with HNC represent a population that is likely to bear a large financial burden during the course of their illness.18,19 As such, access to insurance coverage, particularly for low-income populations, is critical. Higher-income populations are more likely to have been enrolled in an insurance plan prior to implementation of the ACA. Widening access to coverage among populations with financial limitations may thus serve to narrow disparities in access to care.

    Young adults represent a minority of the HNC population and historically have low rates of insurance coverage.20,21 Our results indicate that young adults with HNC experienced a greater increase in insurance coverage through the ACA than did older adults. This may be the result of both ACA provisions and the fact that young adults represent a patient population significantly less likely to have insurance coverage owing to limitations in finances, employment, and insurance literacy.22 Patients older than 65 years already benefited from insurance coverage through Medicare before implementation of the ACA and, as a result, are least likely to demonstrate any coverage changes. Most studies examining how the ACA has affected insurance coverage in the young-adult population have investigated the effects of the 2010 ACA Dependent Coverage Provision, which allowed young adults to be covered by a parent’s insurance policy up to age 26.23 More recently, in studies examining the effects of the ACA’s Medicaid-expansion in 2014, young adults have in fact been found to have the largest decreases in uninsured status of any age group,21,22 which is consistent with our findings in the HNC-specific population.

    This study has several public health implications. Although increasing health insurance coverage removes a major barrier to care for many patients with HNC, many other socioeconomic determinants must be considered when evaluating quality of disease treatment, particularly for historically disadvantaged subpopulations. These may include transportation challenges, poor health literacy, child care responsibilities, late diagnosis, and competing workplace obligations. In the context of broader public health goals, this research will help us understand how expanding insurance coverage affects access to care among patients with HNC who generally present at late stages and with poor prognoses. Our analyses in conjunction with data from similar studies can be leveraged in discussions and forums on insurance reform. Results from this investigation will contribute to an evidence base that can influence policymaking. Stakeholders that may be affected by the results of this investigation include insurance companies, policymakers, politicians, clinicians, and patients. Overall, this study demonstrates that the ACA was effective in increasing insurance coverage for populations of patients with HNC with historically limited access to care, including low-income groups and younger adults with HNC.

    Strengths and Limitations

    A major strength of this study is the large sample size represented by the NCDB. This data set includes patients belonging to a variety of socioeconomic and demographic groups, and those who have sought care at both community and academic care centers. There are also a few limitations to be noted. Owing to the constraints of the NCDB, we were unable to assess variations in insurance coverage across groups in Medicaid expansion vs nonexpansion states. In addition, the NCDB data are based on county-level information rather than individual-level information, which may result in an underrepresentation of the effects of the ACA on socioeconomic factors. Given that this study is based on a historical cohort, we are limited in our ability to draw definitive conclusions regarding the causal effect of the ACA. Furthermore, although these data provided insight into changes in insurance coverage, they do not provide information about the lived experience of patients with HNC nor the amount and quality of care these patients receive. In addition, the insurance definition in the NCDB only reflects the status at diagnosis and thus cannot be used to track individual patients’ insurance status over time. Finally, there may be some misclassification of insurance status, particularly for patients who were uninsured at diagnosis but retroactively enrolled in Medicaid, though this would be expected to bias our results toward the null.24-27 Despite these limitations, this study provides insight into the association of the ACA rollout with increased insurance coverage among patients with HNC, particularly among populations with historically limited health care access.

    Conclusions

    The association of the ACA with changes in insurance coverage across socioeconomic and demographic subgroups of patients with HNC is not well characterized. Our data demonstrate a significant reduction in the overall rate of uninsured patients with HNC after implementation of the ACA. Patients with HNC from low-income zip codes experienced a greater increase in insurance coverage than those from high-income zip codes. In addition, young adults may have experienced a greater increase in access to care in the post-ACA era compared with patients with HNC who belong to older age groups.

    Our study suggests that the ACA was successful in increasing coverage among patients with HNC, a subgroup of patients with cancer whose disease treatment can be particularly complex and costly. Future studies should investigate the association of the ACA with access to evidence-based treatment of HNC, particularly in vulnerable patient populations.

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    Article Information

    Corresponding Author: Neelima Panth, MD, MPH, 200 College St, #338, New Haven, CT 06510 (neelima.panth@yale.edu).

    Accepted for Publication: August 8, 2019.

    Correction: On February 20, 2020, this article was corrected to fix the surname of Dr Osazuwa-Peters, which previously appeared incorrectly in the byline and affiliations sections. This article has been corrected online.

    Published Online: October 31, 2019. doi:10.1001/jamaoto.2019.2724

    Author Contributions: Drs Osazuwa-Peters and Varvares had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Study concept and design: Barnes, Sethi, Varvares, Osazuwa-Peters.

    Acquisition, analysis, or interpretation of data: Panth, Barnes, Osazuwa-Peters.

    Drafting of the manuscript: Panth, Barnes, Sethi, Osazuwa-Peters.

    Critical revision of the manuscript for important intellectual content: Sethi, Varvares, Osazuwa-Peters.

    Statistical analysis: Barnes.

    Administrative, technical, or material support: Panth, Sethi, Osazuwa-Peters.

    Study supervision: Varvares, Osazuwa-Peters.

    Conflict of Interest: None reported.

    Meeting Presentation: This study was presented in part as a podium presentation at the American Head and Neck Society 2019 Annual Meeting held during the Combined Otolaryngology Spring Meetings; May 1, 2019; Austin, Texas.

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