post-ACA Periods Research Articles

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

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. To assess the association of the implementation of the ACA with insurance status across socioeconomic and demographic subpopulations of patients with HNC. 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. Changes in the percentage of patients with insurance. 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). 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.

Coverage and Access for Americans with Cardiovascular Disease or Risk Factors After the ACA: a Quasi-experimental Study.

Atherosclerotic cardiovascular disease (CVD) is the leading cause of death in the USA. Many with CVD or cardiovascular risk factors (CVRFs) lacked insurance coverage and access to care before enactment of the Affordable Care Act (ACA). To assess the effect of the ACA on insurance coverage, access to care, and racial/ethnic disparities among non-elderly adults with CVD or CVRFs. Quasi-experimental policy intervention. Nationally representative, non-institutionalized sample of 1,014,450 adults aged 18 to 64years with CVD or at least 2 established CVRFs in the pre-ACA (2012-2013) and post-ACA (2015-2016) periods. Implementation of ACA provisions on 1 January 2014. Insurance coverage, having a check-up, having a personal physician, and not having to forgo a needed physician visit because of cost. Following ACA implementation, insurance coverage increased by 6.9 percentage points (95% CI, 6.6 to 7.2), not having to forgo a physician visit increased by 3.6 percentage points (CI, 3.3 to 3.9), having a check-up increased by 2.1 percentage points (CI, 1.8 to 2.6), and having a personal physician increased by 1 percentage point (0.6 to 1.3); changes were approximately doubled for those with lower incomes (< $35,000/year). Changes in coverage varied substantially by state and all outcomes improved more in Medicaid expansion states. Although racial/ethnic minorities had greater improvements in some outcomes, approximately 13% black and 29% Hispanic adults continued to lack coverage and access to care post-ACA. The ACA increased coverage and access for adults with CVD or multiple CVRFs; substantial gaps remain, particularly for minorities and those in Medicaid non-expansion states.

Affordable Care Act and cancer stage at diagnosis in an underserved population

The Patient Protection and Affordable Care Act (ACA) has increased insurance coverage among underserved individuals, but the effect of ACA on cancer diagnosis is currently debated, particularly in Medicaid non-expansion states. Therefore, we aimed to assess the effect of ACA implementation on stage at diagnosis among underserved cancer patients in Texas, a Medicaid non-expansion state. We used data from the institutional registry of the JPS Center for Cancer Care, which serves an urban population of underserved cancer patients. Eligible individuals were aged 18 to 64 years and diagnosed with a first primary invasive solid tumor between 2008 and 2015. We used a natural experiment framework and interrupted time-series analysis to assess level (i.e. immediate) and slope (over time) changes in insurance coverage and cancer stage at diagnosis between pre- and post-ACA periods. Our study population comprised 4808 underserved cancer patients, of whom 51% were racial/ethnic minorities. The prevalence of uninsured cancer patients did not immediately change after ACA implementation but modestly decreased over time (PR = 0.94; 95% CL: 0.90, 0.98). The prevalence of early- and advanced-stage diagnosis did not appreciably change overall or when stratified by screen-detectable cancers. Our results suggest that ACA implementation decreased the prevalence of uninsured cancer patients but had little effect on cancer stage at diagnosis in an underserved population. Given that Texas is a Medicaid non-expansion state, Medicaid expansion and alternative approaches may need to be further explored to improve earlier cancer diagnosis among underserved individuals.

Health Status of Young Adults with Insurance Coverage Before and After Affordable Care Act Passage.

The purpose of this study was to assess changes in health status of California young adults with insurance coverage before and after passage of the Affordable Care Act (ACA). For this cross-sectional descriptive study, electronic health record information for young adults between ages 18 and 25 years enrolled in a large Southern California Health Plan in 2008, 2010, or 2015 was obtained (N = 665,686). Absolute changes and standardized annual differences in demographics and age-sex-race standardized prevalence of Elixhauser health conditions for pre-ACA (2008-2010) and post-ACA (2010-2015) periods were calculated. The number of young adults enrolled in the Health Plan increased by 145,000 (65%) during the ACA transition with a shift toward low-income young adults. The increase in high-deductible insurance plans observed pre-ACA stabilized with a standardized annual difference of 0.22 pre-ACA vs 0.05 post-ACA. The prevalences of obesity and other health conditions between pre-ACA and post-ACA periods essentially were unaltered and comparable between young adults who became new members (< 1 year) and those with long-term memberships (≥ 3 years). In this California health care system, the health status of new young adult members was comparable to that of long-term members. Future research should assess whether these young adults retain their health insurance coverage after turning age 26 years and being removed from their parents' insurance plans.

Changes in pediatric dental coverage and visits following the implementation of the affordable care act.

To determine the impact of the inclusion of pediatric dental care in the Affordable Care Act's (ACA) core package of essential health benefits on dental coverage and utilization. Children aged 1-18years included in the nationally representative 2010-2015 National Health Interview Survey (NHIS). We used regression-adjusted difference-in-differences to examine changes in rates of dental coverage and visits pre- and post-ACA for children likely to be affected by the ACA (have a parent working for a small employer) to a comparison group of children who were unlikely to be affected (have a parent in a firm with ≥50 employees). Models adjusted for relevant health and sociodemographic measures. NHIS is an annual household survey conducted by the National Center for Health Statistics. Comparing pre- and post-ACA periods, private dental insurance increased by 4.6 percentage points more (P=0.013) and annual dental visits were unchanged (2.7 percentage points, P=0.071) among children likely to be affected by the ACA compared to children unlikely to be affected by the ACA. Inclusion of pediatric dental care as an ACA essential health benefit increased dental insurance coverage, but not dental visits among children likely to be affected by this policy.

Impact of the Affordable Care Act on elective general surgery clinical practice

BackgroundThe Affordable Care Act (ACA) dramatically changed the healthcare system in the United States. This study aims to analyze the impact of the ACA on general surgery clinic visits and resultant procedures. MethodsA retrospective review was conducted on new patients who presented to the elective general surgery clinic at an academic medical center between Jan. 1, 2012 and Dec. 31, 2015. Based on the open enrollment start date of Jan.1, 2014 patients were divided into pre-ACA and post-ACA periods. Data on demographics, type of insurance, missed appointments, and elective surgical procedures performed were collected. ResultsMedi-Cal insurance coverage increased post-ACA from 20.9% to 56.7%, p < 0.001; self-pay status went from 9.8% to 0%. There were 296 (35.4%) surgical procedures performed pre-ACA and 347 (37.1%) post-ACA (p = 0.445). Missed clinic visits decreased after implementation of the ACA, with 26.8% no-shows pre-ACA and 20.7% no-shows post-ACA (p = 0.003). ConclusionThe ACA had a profound impact on the general surgery clinic with fewer uninsured patients, fewer no-shows and a modest increase in the number of procedures performed. SummaryIn 2014 the Affordable Care Act mandate was implemented. This legislation impacted healthcare by significantly decreasing the number of uninsured patients and increasing overall volume in one general surgery clinic.

Examination of How the Affordable Care Act Influenced Use of Lower-Acuity Emergency Department Services

CONTEXTThe Affordable Care Act (ACA) was implemented to make insurance accessible and reduce healthcare costs. The purpose of this study was to examine for changes in the use of lower-acuity types of Emergency Department (ED) services at two suburban Detroit facilities before, and after implementation of the ACA.METHODSA retrospective chart review of patients presenting to the ED at a two-campus suburban hospital system was performed over two 18-month pre- and post-ACA periods. The authors completed a review of electronic health record data and used ICD-9 code and ED visit billing and collections data. Sample patients included those who had received lower-acuity ED care within the two designated time periods. A total of 16 lower-acuity ICD-9 codes were included to gauge pre and post changes in use of ED services.RESULTSThe authors identified 2,099 patients meeting study criteria during the pre-ACA period and 2,158 patients within the post-ACA period. A subgroup of 166,483 ED patients received care during the pre-ACA time period and 179,879 post-ACA. There was no statistically significant difference between the volume of lower-acuity ED visits during the two analytic periods (i.e., 1.26% seen pre-ACA implementation and 1.20% seen post-ACA). (p = 0.420) Neither did the absolute number of all ED visits significantly change. As could be anticipated, however, the proportion of self-pay patients pre-ACA significantly decreased from 506 (24.1%) to 191 (8.9%) post-ACA. (p < 0.001) Medicaid HMO payments also increased significantly from 824 visits pre-ACA to 1,086 visits post-ACA. (p < 0.001) In addition, Blue Cross coverage increased from 54 visits pre-ACA to 98 visits post-ACA. (p < 0.001)CONCLUSIONSIn summary, our results revealed no significant change in the absolute volume of all ED visits or proportions of lower-acuity ED visits between the pre- and post-ACA periods. As the authors had anticipated, pre and post changes in the number of self-pay patients and those with certain types of insurance coverage were dramatic. The authors conclude that changes in lower-acuity visits to the ED in these study settings had not decreased as envisioned by ACA developers. Future studies with larger longitudinal samples are warranted to more fully investigate the longer-term implications of the ACA on use of ED services.

Changes in Insurance Coverage and Stage at Diagnosis Among Nonelderly Patients With Cancer After the Affordable Care Act.

Purpose To examine change in the percent uninsured and early-stage diagnosis among nonelderly patients with newly diagnosed cancer after the Affordable Care Act (ACA). Patients and Methods By using the National Cancer Data Base, we estimated absolute change (APC) and relative change in percent uninsured among patients with newly diagnosed cancer age 18 to 64 years between 2011 to the third quarter of 2013 (pre-ACA implementation) and the second to fourth quarter of 2014 (post-ACA) in Medicaid expansion and nonexpansion states by family income level. We also examined demographics-adjusted difference in differences in APC between Medicaid expansion and nonexpansion states. We similarly examined changes in insurance and early-stage diagnosis for the 15 leading cancers in men and women (top 17 cancers total). Results Between the pre-ACA and post-ACA periods, percent uninsured among patients with newly diagnosed cancer decreased in all income categories in both Medicaid expansion and nonexpansion states. However, the decrease was largest in low-income patients who resided in expansion states (9.6% to 3.6%; APC, -6.0%; 95% CI, -6.5% to -5.5%) versus their counterparts who resided in nonexpansion states (14.7% to 13.3%; APC, -1.4%; 95% CI, -2.0% to -0.7%), with an adjusted difference in differences of -3.3 (95% CI, -4.0 to -2.5). By cancer type, the largest decrease in percent uninsured occurred in patients with smoking- or infection-related cancers. A small but statistically significant shift was found toward early-stage diagnosis for colorectal, lung, female breast, and pancreatic cancer and melanoma in patients who resided in expansion states. Conclusion Percent uninsured among nonelderly patients with newly diagnosed cancer declined substantially after the ACA, especially among low-income people who resided in Medicaid expansion states. A trend toward early-stage diagnosis for select cancers in expansion states also was found. These results reinforce the importance of policies directed at providing affordable coverage to low-income, vulnerable populations.

Insurance Coverage and Well-Child Visits Improved for Youth Under the Affordable Care Act, but Latino Youth Still Lag Behind

ObjectiveTo examine whether there have been changes in insurance coverage and health care utilization for youth before and after the national implementation of the Patient Protection and Affordable Care Act (ACA) and to assess whether racial and ethnic inequities have improved. MethodsData are from 64,565 youth (ages 0–17 years) participants in the 2011 to 2015 National Health Interview Survey. We conducted multivariate logistic regression analyses to determine how the period after national implementation of the ACA (years 2011–2013 vs years 2014–2015) was associated with health insurance coverage and utilization of health care services (well-child visits, having visited an emergency department, and having visited a physician, all in the past 12 months), and whether changes over the pre- and post-ACA periods varied according to race and Latino ethnicity. ResultsThe post-ACA period was associated with improvements in insurance coverage and well-child visits for all youth. Latino youth had the largest absolute gain in insurance coverage; however, they continued to have the highest proportion of uninsurance post national ACA implementation. With regard to health care equity, non-Latino black youth were less likely to be uninsured and Latino youth had no significant improvements in insurance coverage relative to non-Latino white youth after national ACA implementation. Inequities in health care utilization for non-Latino black and Latino youth relative to non-Latino white youth did not improve. ConclusionsInsurance coverage and well-child visits have significantly improved for all youth since passage of the ACA, but inequities persist, especially for Latino youth.

Abstract A88: A Preliminary Assessment of the Potential Impact of the Affordable Care Act on Breast Cancer Stage

Abstract Background: The Affordable Care Act (ACA) has provided phased-in changes in health care delivery and reimbursement. As of January 1, 2011, the ACA eliminated copayments/co-insurance for recommended preventive services in Medicare beneficiaries including breast cancer screening. Removing out-of-pocket expenses may encourage an uptake of preventative cancer care. Indeed, one study has found that compared with the pre-ACA period (2009-2010), there was a statistically significant increase in mammography uptake during the ACA coverage period (2011-2012). Mammography screening is associated with detection of breast cancer at early stages. Therefore, this provision of the ACA may increase the proportion of early stage diagnoses which are associated with less invasive treatment and improved outcomes. Furthermore, this ACA provision may help ameliorate racial/ethnic disparities in breast cancer stage because minorities are disproportionately represented among those targeted by the coverage provisions of the ACA. The purpose of the present analysis is to examine the impact of the elimination of copayments for screening on breast cancer stage (disparities) in the Medicare population. Methods: This study is a retrospective analysis of patients with breast cancer diagnosed between 2008 and 2013 who were included in the National Cancer Data Base (NCDB). Sponsored by the Commission on Cancer of the American College of Surgeons and the American Cancer Society, the NCDB is a nationwide cancer database that captures approximately 70% of all newly diagnosed cancers in the United States from approximately 1,500 hospitals accredited by the Commission on Cancer. Patients were included if they were: non-Latina (nL) white, nL black, or Latina; diagnosed with Stage I-IV cancer; Medicare-insured at the time of diagnosis; and age 66 years or older. The pre- and post-ACA periods of the preventative services provision were identified as 2008-2009 and 2011-2013, respectively. The year 2010 wastreated as a washout/phase-in period and was excluded. A pre-post design was used to examine a shift in the distribution of cancer stage and compare changes by race/ethnicity. Proportion differences were calculated. The binomial model with a link function was used to adjust differences by age and zip code-level economic indicators (i.e. median household income, percent with high school education). Results: We identified 213, 385 nL white, 21,452 nL black, and 7,980 Latina patients with an incident breast cancer diagnosis. Between the pre- and post-ACA periods, there was a statistically significant shift in the distribution of cancer stage. The proportion of Stage I cancers increased from 55.6% to 58.1% while it decreased for Stage II cancers from 29.5 to 27.9% (p&amp;lt;0.0001). The increase in the proportion of Stage I cancer was highest for Latina (50.4% to 55.1%, p&amp;lt;0.0001) and nL black patients (44.5% to 47.9%, p&amp;lt;0.01) and lowest for nL white patients (56.9% to 59.3%, p&amp;lt;0.0001). After adjusting for age, income, and education, these differences were slightly attenuated. In addition, the Latina/nL white proportion difference in Stage I cancer diagnoses was reduced by 2.4 percentage points whereas the nL black/nL white difference was reduced by 0.2 percentage point. Conclusion: The ACA's elimination of copayments/co-insurance for preventive services such as cancer screening may have a meaningful impact on cancer outcomes. A preliminary assessment shows that it may lead to a shift in earlier stage breast cancers. The elimination of these out-of-pocket expenses for mammograms may particularly benefit Latina women who tend to have lower screening rates. These study findings should be interpreted in light of its limitations such as its cross-sectional design and lack of mammography screening assessment. More research is needed to understand the impact of the ACA on cancer care and outcomes. Citation Format: Abigail Silva, Talar Markossian, Yamile Molina. A Preliminary Assessment of the Potential Impact of the Affordable Care Act on Breast Cancer Stage. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr A88.

Cancer preventive services, socioeconomic status, and the Affordable Care Act

Out-of-pocket expenditures are thought to be an important barrier to the receipt of cancer preventive services, especially for those of a lower socioeconomic status (SES). The Affordable Care Act (ACA) eliminated out-of-pocket expenditures for recommended services, including mammography and colonoscopy. The objective of this study was to determine changes in the uptake of mammography and colonoscopy among fee-for-service Medicare beneficiaries before and after ACA implementation. Using Medicare claims data, this study identified women who were 70 years old or older and had not undergone mammography in the previous 2 years and men and women who were 70 years old or older, were at increased risk for colorectal cancer, and had not undergone colonoscopy in the past 5 years. The receipt of procedures in the 2-year period before the ACA's implementation (2009-2010) and after its implementation (2011 to September 2012) was also identified. Multivariate generalized estimating equation models were used to determine the independent association and county-level quartile of median income and education with the receipt of testing. For mammography, a lower SES quartile was associated with less uptake, but the post-ACA disparities were smaller than those in the pre-ACA period. In addition, mammography rates increased from the pre-ACA period to the post-ACA period in all SES quartiles. For colonoscopy, in both the pre- and post-ACA periods, there was an association between uptake and educational level and, to some extent, income. However, there were no appreciable changes in colonoscopy and SES after implementation of the ACA. The removal of out-of-pocket expenditures may overcome a barrier to the receipt of recommended preventive services, but for colonoscopy, other procedural factors may remain as deterrents. Cancer 2017;123:1585-1589. © 2017 American Cancer Society.