Objectives: The Patient Protection and Affordable Care Act (ACA) was a significant regulatory overhaul to the US healthcare system. The majority of the provisions came into effect January 2014, including expanding Medicaid eligibility and providing subsidies for health insurance premiums to low-income adults near the federal poverty level, providing a federal health insurance exchange, and enforcing a mandate that individuals buy insurance. Head and neck cancer patients are often uninsured or underinsured at the time of their diagnosis and this access to care has been shown to influences treatment decisions and survival outcomes. The Surveillance, Epidemiology, and End Results (SEER) database is an epidemiological tool that was designed to be representative of the US population as a whole. Therefore, the objective of this study is to examine the impact of the ACA health care legislation on insurance rates and access to care among patients with head and neck squamous cell cancer in this large aggregate national dataset.
Methods: All patients with newly diagnosed aerodigestive tract head and neck squamous cell cancer from 2007 to 2014 were extracted from the SEER database. During this time period, prospective population-based tumor registries were available from 18 areas. Insurance rates were examined before and after the ACA Medicaid expansion, insurance mandate and subsidies, and opening of the health insurance marketplace to examine the impact of this health care policy, before (January 2007-December 2013) versus after (January 2014-December 2014). Rates of insurance were then compared between states that elected to expand Medicaid coverage in 2014 versus those states that decided to opt out.
Results: There were 89,038 patients who met the inclusion criteria. Among these patients newly diagnosed with aerodigestive tract head and neck squamous cell cancer, there was a significant increase in patients enrolled in Medicaid (16.4% versus 14.1%; p<0.001) and private insurance (80.8% versus 76.6%; p<0.001) after implementation of the ACA. In addition, there was a significant decrease in the rates of uninsured patients (4.8% versus 2.7%; p<0.001). Uninsured rates decreased by approximately 50% for head and neck squamous cell cancer patients after January 2014. This decrease in the rate of the uninsured and associated increases in Medicaid and private insurance coverage were only significantly observed in the states which adopted Medicaid expansion in 2014 (p<0.001).
Conclusion: Access to health care for head and neck cancer patients was improved after implementation of the ACA, with an increase in both Medicaid and private insurance rates and a 2-fold decrease in uninsured patients, however, the impact of this health care policy was only significantly demonstrated in states which adopted the Medicaid expansion decision in 2014.