Abstract
Health insurance coverage is dynamic in the United States, potentially changing from month to month. The Patient Protection and Affordable Care Act (ACA) aimed to stabilize markets and reduce financial burden, particularly among those with preexisting conditions. To describe the risks of insurance churn (ie, gain, loss, or change in coverage) and catastrophic health expenditures among nonelderly patients with cancer in the United States, assessing for changes associated with ACA implementation. This retrospective, cross-sectional study uses data from the Medical Expenditure Panel Survey, a representative sample of the US population from 2005 to 2018. Respondents included were younger than 65 years, identified by health care use associated with a cancer diagnosis code in the given year. Statistical analysis was conducted from July 30, 2020, to January 5, 2021. The Patient Protection and Affordable Care Act. Survey weights were applied to generate estimates for the US population. Annual risks of insurance churn (ie, any uninsurance or insurance change or loss) and catastrophic health expenditures (spending >10% income) were calculated, comparing subgroups with the adjusted Wald test. Weighted multivariable linear regression was used to assess for changes associated with ACA implementation. From 6069 respondents, we estimated a weighted mean of 4.78 million nonelderly patients (95% CI, 4.55-5.01 million; female patients: weighted mean, 63.9% [95% CI, 62.2%-65.7%]; mean age, 50.3 years [95% CI, 49.7-50.8 years]) with cancer annually in the United States. Patients with cancer experienced lower annual risks of insurance loss (5.3% [95% CI, 4.5%-6.1%] vs 7.6% [95% CI, 7.4%-7.8%]) and any uninsurance (14.6% [95% CI, 13.3%-16.0%] vs 24.1% [95% CI, 23.5%-24.7%]) but increased risk of catastrophic health expenditures (expenses alone: 12.4% [95% CI, 11.2%-13.6%] vs 6.3% [95% CI, 6.2%-6.5%]; including premiums: 26.6% [95% CI, 25.0%-28.1%] vs 16.5% [95% CI, 16.1%-16.8%]; P < .001) relative to the population without cancer. Patients with cancer from low-income families and with full-year private coverage were at particularly high risk of catastrophic health expenditures (including premiums: 81.7% [95% CI, 74.6%-88.9%]). After adjustment, low income was the factor most strongly associated with both insurance churn and catastrophic spending, associated with annual risk increases of 6.5% (95% CI, 4.2%-8.8%) for insurance loss, 17.3% (95% CI, 13.4%-21.2%) for any uninsurance, and 37.4% (95% CI, 33.3%-41.6%) for catastrophic expenditures excluding premiums (P < .001). In adjusted models relative to 2005-2009, full ACA implementation (2014-2018) was associated with a decreased annual risk of any uninsurance (-4.2%; 95% CI, -7.4% to -1.0%; P = .01) and catastrophic spending by expenses alone (-3.0%; 95% CI, -5.3% to -0.8%; P = .008) but not including premiums (0.4%; 95% CI, -2.8% to 4.5%; P = .82). In this cross-sectional study, US patients with cancer faced significant annual risks of insurance churn and catastrophic health spending. Despite some improvements with ACA implementation, large burdens remained, and further reform is needed to protect this population from excessive hardship.
Highlights
Despite some improvements with Affordable Care Act (ACA) implementation, large burdens remained, and further reform is needed to protect this population from excessive hardship
Demographic Characteristics We considered demographic characteristics reported in Medical Expenditure Panel Survey (MEPS) that might be associated with health care spending and insurance coverage, including age, sex, race (White, Black, and other or mixed), Hispanic ethnicity, immigrant status, low educational level, job change, marital status, family size, family income in association with the federal poverty level (FPL; Յ138% FPL, 139%-250% FPL, 251%-400% FPL, and >400% FPL),[20] and self-reported comorbidities
Study Sample We identified a total of 6069 MEPS respondents younger than 65 years reporting cancer in a given year during 2005-2018 (4280 unique individuals owing to sampling over 2 years), extrapolating to an estimated annual mean of 4.78 million nonelderly patients in the United States with health care use associated with a cancer diagnosis in the given year
Summary
Patients with cancer are vulnerable to high out-of-pocket spending, largely owing to frequent interactions with the medical system and high drug prices,[1,2,3,4] with uninsured individuals at particular risk of financial catastrophe.[5,6] Insurance coverage is often studied as a static variable, as reported in databases, usually at the time of diagnosis.[7,8] coverage for nonelderly individuals in the United States is dynamic, and insurance churn (ie, gain, loss, or change in coverage) is present even in times of near-universal access to coverage, such as during pregnancy.[9,10,11,12] Receiving a diagnosis of cancer has been associated with employment disruptions that may affect both income and insurance coverage,[13] yet we have limited understanding of insurance dynamics and financial burden in this population.The Patient Protection and Affordable Care Act (ACA) was passed in 2010 with the aim of reducing patients’ financial burden, primarily through improving access to insurance coverage in the US.[14,15] Patients in the US with cancer were targeted by protections against discrimination on preexisting conditions and new regulations to prevent catastrophic out-of-pocket health spending, both of which took effect soon after the law was signed.[16]. Coverage access improvements through Medicaid expansion and state exchanges began in January 2014.17 The ACA had the potential to improve coverage continuity and reduce financial burden for patients in the US with cancer
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Free) 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call
