The dependent coverage provision in the Affordable Care Act has helped adolescent and young adult patients with cancer stay on health insurance longer than those who had cancer before the ACA was signed into law.
The insurance dropout rate among adolescents and young adult cancer survivors may have been lowered due to the dependent coverage provision in the Affordable Care Act, according to the findings of a new study.
Signed into law on March 23, 2010, the Affordable Care Act (ACA) was the biggest change to the American health care system since the adoption of Medicare and Medicaid. Among its provisions, such as protection of denying insurance for pre-existing conditions like cancer, was the dependent coverage provision (DCP) that allowed enrollees to remain on their parent’s health insurance up until they turned 26 years old. This was regardless whether they were married, not living with their parents, still in school, not financially dependent on their parents or eligible to enroll on their employer’s health, according to the Department of Health &Human Services.
“Our biggest finding is that patients who are impacted by the Affordable Care Act, meaning that they were between age 19 and 25 at the time that the Affordable Care Act went into effect in 2010, that those patients had longer periods before they either lost or changed their insurance,” said lead study author Dr. Lena Winestone a pediatric oncologist and assistant professor at UCSF Benioff Children’s Hospital, in an interview with CURE®.
Looking at real world data of young adult patients with cancer, Winestone, and colleagues matched 2,829 patients who turned 19 years-old in the two years following the implementation of the ACA to patients who turned 19 from 2007 to 2009. They found the median time to disenrollment was 26 months for younger patients compared to 22 months for older patients.
In comparison, the authors analyzed 8,978 patients who turned 19 between 2001 and 2006 and noted that the median time to disenrollment was 20 months among both groups. The authors also found a 15% greater reduction in loss of coverage in both cohorts of the study that favored patients who turned 19 after the DCP went into effect.
This showed how patients were staying on insurance longer past the period most insurances would cover for pediatric patients aged 18 years or younger and some who were still in school. The DCP allowed patients to stay on their insurance longer, and it is the authors’ hypothesis that by having the option to stay insured through their parents longer that overall time on insurance lasted longer for this population.
“When we look beyond that period, in particular, there's a very vulnerable period where it's difficult to get employment. Often, students are still in school but don't qualify either because of their age or because of the type of insurance (they had). And so, the Affordable Care Act was specifically designed to address that vulnerable population,” explained Winestone. “That's an overlapping vulnerable population with a pediatric oncology population. We know that adolescents and young adults, regardless of insurance issues, have more difficulty with adhering to care and have more difficulty with maintaining access to care. And we know that they also have worse outcomes.”
However, the authors were surprised, according to Winestone, of the high turnover rate of insurance that young adult patients experienced even with the DCP potentially expanding their time on insurance. This was something they attributed to the framework of health care in America revolving around employment-based care. They also found that while recent and older eras of patients differed in time to disenrollment, Hispanic and Black patients were 9% to 14% more likely to disenroll compared to white and non-Hispanic populations of patients.
Overall, younger patients were more likely to retain insurance coverage over a four-year period compared to older patients (37% versus 31%). Of the more than 60% of patients who disenrolled, about 15% eventually re-enrolled on a commercial health plan.
Increasing this enrollment period and ability to retain insurance is vital for the young adult cancer survivor population as treatment related side effects from treatments like chemotherapy can follow patients through the rest of their life, said Winestone. They will require extra care during survivorship, moreover, they now have a pre-existing condition.
These results come as policymakers debate the future of the ACA with a major Supreme Court case set to be heard next month that could repeal the ACA entirely. A repeal could put into question the future of the DCP and other protections of the ACA like that for pre-existing conditions.
“A separate part of the Affordable Care Act covers this question of pre-existing conditions. And basically, anyone who has a previous diagnosis of cancer falls into that category,” explained Winestone. “And it is particularly essential for the (young adult) patient population to receive ongoing regular care in a way that's different than a healthy 24-year-old who's never had cancer.”
As the debate around the ACA continues, there has been no comprehensive replacement plan, or existing law, that has been put forth that would take the place of the prohibition under the ACA to stop insurance companies from considering pre-existing conditions for denying coverage, according to Dr. Susan Dorr Goold, a physician and professor at the University of Michigan Institute for Healthcare Policy and Innovation. This could impact the chances of young adults to obtain insurance as they get older and enter the general population as cancer survivors.
The DCP is a popular part of the ACA and one that Winestone said she believes has acceptance across party lines, but the DCP would still be repealed along with the ACA if the Supreme Court finds it unconstitutional. The case in November is only calling into question the individual mandate, a part of the ACA that has not impacted young adult cancer survivors in the same way as other patients.
“Those pieces are pieces that, you know, I think as we continue to demonstrate how important they are, hopefully, that helps support the ACA kind of remaining as part of our public policy,” Winestone said.
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