Affordable Care Act reduced rate of uninsured patients with head and neck cancers

Reviewed by Kate Anderton, B.Sc. (Editor)Nov 5 2019

The rate of uninsured patients with head and neck cancers was "significantly reduced" following the implementation of the federal Patient Protection and Affordable Care Act (ACA).

The percentage of patients with head and neck cancer without insurance dropped from 7.7% in the pre-ACA period to 4.9% in the post-ACA period.

The findings, led by Nosayaba Osazuwa-Peters, BDS, Ph.D., MPH, of Saint Louis University's Department of Otolaryngology, were published online Oct. 31 in the latest issue of the journal JAMA Otolaryngology.

In the U.S., approximately 64,000 people are diagnosed with head and neck cancer each year and more than 14,000 die of disease-specific causes. Insurance status, Osazuwa-Peters said, is a major factor in the outcome for head and neck cancer patients.

Treating head and neck cancer is generally complicated. You can tell that just thinking about the complex anatomic structures in the head and neck region impacted by cancer. Besides this and other very important clinical factors associated with treatment, this study built on our previous studies, as well as other studies, that have shown that patients without health insurance are more likely to present with more advanced-stage disease. The problem is, the more advanced the disease, the more complicated the treatment is, and typically, the worse the prognosis.

One of the benefits the ACA was supposed to provide is to reduce the disparity associated with access to care, which has been a historical problem in head and neck cancer care. Historically, cancer patients, including head and neck patients, did not all receive the same quality of care based on their insurance status, race/ethnicity, sex, or other factors that have nothing to do with their disease. This inequality was one of the issues the ACA was supposed to ameliorate."

Nosayaba Osazuwa-Peters, BDS, Ph.D., MPH, Saint Louis University's Department of Otolaryngology

The researchers found there was a significant difference in the changes in the percentage of uninsured patients by age, with the largest reduction of uninsured patients coming among the 18 to 34-year-old age range and the smallest in the oldest population, those aged 65-74.

Women were also more likely to be insured than men following the passage of the ACA.

The ACA has expanded insurance coverage in the United States, increasing the access to care for millions of people. Osazuwa-Peters said their research found a significantly greater reduction in the percentage of uninsured patients – 3.5% – in low-income zip codes after ACA implementation than in high-income zip codes.

Osazuwa-Peters and his co-authors say the while increasing health insurance coverage removes a major barrier to care for many patients, other socio-economic determinants must be considered when evaluating the quality of disease treatment. These may include transportation challenges, poor health literacy, childcare responsibilities, late diagnosis and competing work-place obligations.

"This research will help us understand how expanding insurance coverage affects access to care among patients with head and neck cancer who generally present at late stages and with poor prognoses," the authors wrote.

The authors used the National Cancer Database (NCDB), querying data on adults aged 18-74, diagnosed with a first-time primary head or neck malignant abnormality between 2011-15. The authors evaluated changes in the percentage of uninsured patients from 2011-13 (pre-ACA) to 2014-15 (post-ACA).

The NCDB is a nationwide hospital-based cancer database containing 70% of all newly diagnosed cancers in the United States. It is a result of a collaboration between the Commission on Cancer, the American Cancer Society and the American College of Surgeons.

There were 77,071 patients diagnosed with head and neck cancer between 2011-13 and 54,708 patients diagnosed between 2014-15. The cohort was 80.6% non-Hispanic white, 74.5% male and 55.5% aged between 50-64 years of age. Most – 108,140 or 82.1% – resided in metropolitan areas.

Patients fell relatively evenly across an income spectrum, with 20% considered low income, 24.6% mid-low, 26.5% mid-high and 28.7% considered high income.

Take-aways

• Head and neck cancer is among the most expensive cancers to treat
• Head and neck cancer patients represent a population that is likely to bear a large financial burden during their illness
• Findings show an uptick in insurance coverage among head and neck cancer patients meaning more of them can afford the cost of their care
• More patients became insured under the ACA in low-income zip codes, compared with high-income zip codes

Owing to the constraints of the NCDB data set, authors were unable to assess variations in insurance coverage across groups in Medicaid expansion versus non-expansion states. The NCDB insurance definition only reflects a patient's status at the time of diagnosis, and thus cannot be used to track individual patients' insurance status over time.

The authors recommend further studies into the association of ACA with access to evidence-based treatment of head and neck cancers, particularly in vulnerable populations.