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Changes in Health Insurance Coverage Associated With the Affordable Care Act Among Adults With and Without a Cancer History: Population-based National Estimates

Davidoff, Amy, J., PhD*,†; Guy, Gery, P., Jr, PhD; Hu, Xin, MSPH; Gonzales, Felisa, PhD§; Han, Xuesong, PhD; Zheng, Zhiyuan, PhD; Parsons, Helen, PhD; Ekwueme, Donatus, U., PhD; Jemal, Ahmedin, DVM

doi: 10.1097/MLR.0000000000000876
Original Article

Background: The Affordable Care Act (ACA) improved health care coverage accessibility by expanding Medicaid eligibility, creating insurance Marketplaces, and subsidizing premiums. We examine coverage changes associated with ACA implementation, comparing adults with and without a cancer history.

Methods: We included nonelderly adults from the 2012 to 2015 National Health Interview Survey. Using information on state Medicaid policies (2013), expansion decisions (2015), family structure, income, insurance offers, and current coverage, we assigned adults in all 4 years to mutually exclusive eligibility categories including: Medicaid-eligible pre-ACA; expansion eligible for Medicaid; and Marketplace premium subsidy eligible. Linear probability regressions estimated pre-post (2012–2013 vs. 2014–2015) coverage changes by eligibility category, stratified by cancer history.

Results: The uninsured rate for cancer survivors decreased from 12.4% to 7.7% (P<0.001) pre-post ACA implementation. Relative to income >400% of the federal poverty guideline, the uninsured rate for cancer survivors decreased by an adjusted 8.4 percentage points [95% confidence interval (CI), 1.3–15.6] among pre-ACA Medicaid eligible; 16.7 percentage points (95% CI, 9.0–24.5) among expansion eligible, and 11.3 percentage points (95% CI, −0.8 to 23.5, with a trend P=0.069) for premium subsidy eligible. Decreases in uninsured among expansion-eligible adults without a cancer history [9.7 percentage points (95% CI, 7.4–12.0), were smaller than for cancer survivors (with a trend, P=0.086)]. Despite coverage gains, ∼528,000 cancer survivors and 19.1 million without a cancer history remained uninsured post-ACA, yet over half were eligible for Medicaid or subsidized Marketplace coverage.

Conclusions: ACA implementation was associated with large coverage gains in targeted expansion groups, including cancer survivors, but additional progress is needed.

*Department of Health Policy and Management, Yale School of Public Health

Cancer Outcomes, Public Policy, and Effectiveness Research Center, Yale School of Medicine, New Haven, CT

Division of Cancer Prevention and Control, Centers for Disease Control and Prevention

§Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD

Surveillance and Health Services Research Program, American Cancer Society, Atlanta, GA

Research Data Assistance Center (ResDAC), University of Minnesota, Minneapolis, MN

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or the National Institutes of Health.

Supported by institutional support from Yale Cancer Center, and intramural support from the American Cancer Society, and the Centers for Disease Control and Prevention and National Cancer Institute. No external funding was provided for this research.

Preliminary results from this study were presented at the American Society for Clinical Oncology Annual meeting in June 2017.

The study was deemed to not directly involve human subjects by the Yale University Human Investigations Committee.

A.J.D. has a family member who receives research funding from Celgene. A.J.D. receives research funding from the Commonwealth Fund and PhRMA Foundation. The remaining authors declare no conflict of interest.

Reprints: Amy J. Davidoff, PhD, Yale School of Public Health, P.O. Box 20834, 60 College Street, New Haven, CT 06405. E-mail: amy.davidoff@yale.edu.

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