Churn and catastrophe: insurance loss and high spending among patients with gynecologic cancer in the United States in the era of the Affordable Care Act

Abstract

<h3>Objectives:</h3> Although often considered a static characteristic in oncology research, insurance coverage is dynamic in reality, potentially changing month-to-month. The Affordable Care Act (ACA) was passed in 2010 with aims of stabilizing and expanding insurance markets, and reducing financial burden, particularly for the poor and sick. We sought to assess insurance churn and catastrophic health expenditures (CHE) among patients with gynecologic cancer in the era of the ACA. <h3>Methods:</h3> Retrospective study of 2006-2017 Medical Expenditure Panel Survey (MEPS) respondents under age 65 reporting care in the given year related to a gynecologic cancer diagnosis. MEPS is an annual survey representative of the civilian, non-institutionalized US population. Weights were applied to estimate national rates of insurance churn (loss/change of coverage) and CHE (family out-of-pocket health spending >10% family income), and differences between subgroups and over time were assessed by the adjusted Wald test. <h3>Results:</h3> A total of 684 MEPS respondents under age 65 reported care related to a gynecologic cancer diagnosis in 2006-2017, representing an estimated average annual population of 533,000 persons (95% CI 462,000-603,000), which was majority White (87.0%) and non-Hispanic (85.5%). Relative to the overall under 65 US population, patients with gynecologic cancer reported higher rates of low-income (family income ≤250% federal poverty level; 45.1% vs 32.2%; <i>p</i><0.001) and employment disruption (15.2% job change/loss, 55.3% part-year unemployment, 38.6% full-year unemployment, vs 10.5%, 44.1%, and 32.4% respectively; <i>p</i><0.05 for all). In the era of the ACA since becoming law in 2010, patients with gynecologic cancer reported high annual rates of insurance churn: 8.8% (95% CI 5.2-12.5) with loss of insurance, 18.7% (95% CI 13.6-23.8) with change in insurance, 21.7% (95% CI 16.5-26.9) uninsured for at least one month, and 8.4% (95% CI 5.7-11.0) uninsured for entire year. The gynecologic cancer population also experienced high rates of catastrophic spending, with 12.8% (95% CI 8.9-16.7) reporting CHE by out-of-pocket expenses alone, and 28.0% (95% CI 21.6-34.4) when including premium spending. Non-white and Hispanic patients collectively reported elevated rates of insurance churn (25.9% insurance change, 30.2% any uninsurance, vs 16.3% and 18.7% respectively for non-Hispanic whites, <i>p</i><0.05 for both), but no difference in rates of CHE. Patients from low-income families faced significantly higher risk of CHE (22.7% vs 3.0% expenses alone, <i>p</i><0.001; 35.3% vs 20.8% including premiums, <i>p</i>=0.01). Full-year Medicaid coverage was more protective from CHE compared with full-year private coverage (overall 15.3% vs 31.3%, <i>p</i>=0.02; low-income 11.5% vs 62.1%, <i>p</i><0.001). In assessment for impact of the ACA comparing full ACA implementation in 2014-17 with pre-ACA years 2006-09, we observed trends towards lower rates of CHE among low-income gynecologic cancer patients after implementation, but no significant differences. <h3>Conclusions:</h3> Gynecologic cancer patients face high rates of insurance churn, with over one in five reporting uninsurance for least one month every year, and catastrophic health spending, with over one in four reporting CHE annually. Low-income patients face the highest risks of CHE, and are better protected with Medicaid coverage as compared to private insurance. There was no significant impact of the ACA, but small sample size limited estimate precision and power to detect small changes.