Improved Survival of Young Adults with Cancer Following the Passage of the Affordable Care Act

Abstract

Background: Compared with their ensured counterparts, uninsured adolescents and young adults (AYAs) with cancer are more likely to present with advanced disease and have poor prognoses. The Patient Protection and Affordable Care Act (ACA), enacted in 2010, provided health care coverage to millions of uninsured young adults by allowing them to remain on their parents' insurance until age 26 years (the Dependent Care Expansion, DCE). The impact of the expansion of insurance coverage on survival outcomes for young adults with cancer has not been assessed.

Participants: Utilizing the Surveillance, Epidemiology, and End Results database, we identified all patients aged 12-16 (younger-AYAs), 19-23 (middle-AYAs), and 26-30 (older-AYAs) who were diagnosed with cancer between 2006-2008 (pre-ACA) and 2011-2013 (post-ACA).

Methods: In this population-based cohort study, we used an accelerated failure time model to assess changes in survival rates before and after the enactment of the ACA DCE.

Results: Middle-AYAs ages 19-23 (thus eligible to remain on their parents' insurance) experienced significantly increased 2-year survival after the enactment of the ACA DCE (survival time ratio 1.25, 95% confidence interval: 0.75-2.43, P = .029) and that did not occur in younger-AYAs (ages 12-16). Patients with sarcoma and acute myeloid leukemia accounted for the majority of improvement in survival. Middle-AYAs of hispanic ethnicity and those with low socioeconomic status experienced trends of improved survival after the ACA DCE was enacted.

Conclusion: Survival outcomes improved for young adults with cancer following the expansion of health insurance coverage. Efforts are needed to expand coverage for the millions of young adults who do not have health insurance.

Keywords: Affordable Care Act; cancer; health insurance; young adult.

Figure 1.

Unadjusted Kaplan-Meier summaries of overall survival comparing diagnoses pre- and post- enactment of the Affordable Care Act Dependent Coverage Expansion (ACA DCE). (A) Overall survival estimates by age group. The overall survival estimates of middle-AYAs and older-AYAs were higher for those diagnosed post-ACA DCE. There were no differences in survival estimates for younger-AYAs. (B) Overall survival estimate for all AYA age categories combined by sex. The overall survival estimates for both females and males diagnosed post-ACA DCE was higher than those diagnosed pre-ACA DCE. (C) Overall survival estimates for all AYA age categories combined by race/ethnicity. Overall survival estimate for Hispanics diagnosed post-ACA DCE was higher than that for Hispanics diagnosed pre-ACA DCE. There were no differences in overall survival estimates pre- and post-ACA DCE for non-Hispanic Asian or Pacific Islanders, non-Hispanic Blacks, or non-Hispanic Whites. (D) Overall survival estimates for all AYA age categories combined by socioeconomic status (SES) tertile. There were no differences in overall survival estimates pre- and post-ACA DCE for those in the highest (tertile 1) SES category. Patients in the middle (tertile 2) and lowest (tertile 3) SES categories had improved survival post-ACA DCE.