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Kirchhoff AC, Waters AR, Liu Q, Ji X, Yasui Y, Yabroff KR, Conti RM, Huang IC, Henderson T, Leisenring WM, Armstrong GT, Nathan PC, Park ER. Health insurance among survivors of childhood cancer following Affordable Care Act implementation. J Natl Cancer Inst 2024; 116:1466-1478. [PMID: 38741226 DOI: 10.1093/jnci/djae111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 03/28/2024] [Accepted: 05/09/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND The Affordable Care Act (ACA) increased private nonemployer health insurance options, expanded Medicaid eligibility, and provided preexisting health condition protections. We evaluated insurance coverage among long-term adult survivors of childhood cancer pre- and post-ACA implementation. METHODS Using the multicenter Childhood Cancer Survivor Study, we included participants from 2 cross-sectional surveys: pre-ACA (2007-2009; survivors: n = 7505; siblings: n = 2175) and post-ACA (2017-2019; survivors: n = 4030; siblings: n = 987). A subset completed both surveys (1840 survivors; 646 siblings). Multivariable regression models compared post-ACA insurance coverage and type (private, public, uninsured) between survivors and siblings and identified associated demographic and clinical factors. Multinomial models compared gaining and losing insurance vs staying the same among survivors and siblings who participated in both surveys. RESULTS The proportion with insurance was higher post-ACA (survivors pre-ACA 89.1% to post-ACA 92.0% [+2.9%]; siblings pre-ACA 90.9% to post-ACA 95.3% [+4.4%]). Post-ACA insurance increase in coverage was higher among those aged 18-25 years (survivors: +15.8% vs +2.3% or less ages 26 years and older; siblings +17.8% vs +4.2% or less ages 26 years and older). Survivors were more likely to have public insurance than siblings post-ACA (18.4% vs 6.9%; odds ratio [OR] = 1.7, 95% confidence interval [CI] = 1.1 to 2.6). Survivors with severe chronic conditions (OR = 4.7, 95% CI = 3.0 to 7.3) and those living in Medicaid expansion states (OR = 2.4, 95% CI = 1.7 to 3.4) had increased odds of public insurance coverage post-ACA. Among the subset completing both surveys, low- and mid-income survivors (<$40 000 and <$60 000, respectively) experienced insurance losses and gains in reference to highest household income survivors (≥$100 000), relative to odds of keeping the same insurance status. CONCLUSIONS Post-ACA, more childhood cancer survivors and siblings had health insurance, although disparities remain in coverage.
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Affiliation(s)
- Anne C Kirchhoff
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
- Cancer Control and Population Sciences Research Program, Huntsman Cancer Institute, Salt Lake City, UT, USA
| | - Austin R Waters
- Cancer Control and Population Sciences Research Program, Huntsman Cancer Institute, Salt Lake City, UT, USA
- Department of Health Policy and Management, University of North Carolina, Chapel Hill, NC, USA
| | - Qi Liu
- Department of Public Health Sciences, University of Alberta, Edmonton, AB, Canada
| | - Xu Ji
- Department of Pediatrics, Emory University School of Medicine/AFLAC Cancer & Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
| | - K Robin Yabroff
- Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA, USA
| | - Rena M Conti
- Department of Markets, Public Policy, and Law, Boston University Questrom School of Business, Boston, MA, USA
| | - I-Chan Huang
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Tara Henderson
- Department of Pediatrics, University of Chicago, Comer Children's Hospital, Chicago, IL, USA
| | - Wendy M Leisenring
- Clinical Research and Public Health Science Divisions, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Paul C Nathan
- Department of Pediatrics and Health Policy, Division of Hematology/Oncology, The Hospital for Sick Children, The University of Toronto, Toronto, ON, Canada
| | - Elyse R Park
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
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Islami F, Baeker Bispo J, Lee H, Wiese D, Yabroff KR, Bandi P, Sloan K, Patel AV, Daniels EC, Kamal AH, Guerra CE, Dahut WL, Jemal A. American Cancer Society's report on the status of cancer disparities in the United States, 2023. CA Cancer J Clin 2024; 74:136-166. [PMID: 37962495 DOI: 10.3322/caac.21812] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 09/07/2023] [Indexed: 11/15/2023] Open
Abstract
In 2021, the American Cancer Society published its first biennial report on the status of cancer disparities in the United States. In this second report, the authors provide updated data on racial, ethnic, socioeconomic (educational attainment as a marker), and geographic (metropolitan status) disparities in cancer occurrence and outcomes and contributing factors to these disparities in the country. The authors also review programs that have reduced cancer disparities and provide policy recommendations to further mitigate these inequalities. There are substantial variations in risk factors, stage at diagnosis, receipt of care, survival, and mortality for many cancers by race/ethnicity, educational attainment, and metropolitan status. During 2016 through 2020, Black and American Indian/Alaska Native people continued to bear a disproportionately higher burden of cancer deaths, both overall and from major cancers. By educational attainment, overall cancer mortality rates were about 1.6-2.8 times higher in individuals with ≤12 years of education than in those with ≥16 years of education among Black and White men and women. These disparities by educational attainment within each race were considerably larger than the Black-White disparities in overall cancer mortality within each educational attainment, ranging from 1.03 to 1.5 times higher among Black people, suggesting a major role for socioeconomic status disparities in racial disparities in cancer mortality given the disproportionally larger representation of Black people in lower socioeconomic status groups. Of note, the largest Black-White disparities in overall cancer mortality were among those who had ≥16 years of education. By area of residence, mortality from all cancer and from leading causes of cancer death were substantially higher in nonmetropolitan areas than in large metropolitan areas. For colorectal cancer, for example, mortality rates in nonmetropolitan areas versus large metropolitan areas were 23% higher among males and 21% higher among females. By age group, the racial and geographic disparities in cancer mortality were greater among individuals younger than 65 years than among those aged 65 years and older. Many of the observed racial, socioeconomic, and geographic disparities in cancer mortality align with disparities in exposure to risk factors and access to cancer prevention, early detection, and treatment, which are largely rooted in fundamental inequities in social determinants of health. Equitable policies at all levels of government, broad interdisciplinary engagement to address these inequities, and equitable implementation of evidence-based interventions, such as increasing health insurance coverage, are needed to reduce cancer disparities.
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Affiliation(s)
| | | | | | | | | | - Priti Bandi
- American Cancer Society, Atlanta, Georgia, USA
| | | | | | | | | | - Carmen E Guerra
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Loecher N, Tran JT, Kosyluk K. Parental Perspectives on Health Care Transition in Adolescent and Young Adult Survivors of Pediatric Cancer. J Adolesc Young Adult Oncol 2023; 12:461-471. [PMID: 36459103 DOI: 10.1089/jayao.2022.0097] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
The health care transition (HCT) from pediatric to adult care is pivotal for childhood cancer survivors (CCS) and their parents. However, there is little research examining parental needs during HCT, despite this being a key predictor of successful HCT. The goal of this study was to investigate the needs of parents of CCS during HCT. Using an integrative review of the literature structured around the social-ecological model (SEM) of CCS transition readiness yielded 454 articles, including three hand-searched articles. Six articles were included in the final analysis. Data were extracted into nine factors derived from SEM. Articles were published within the last decade, largely qualitative, and mainly examined parents and CCS together. Parents most frequently mentioned relationships with their practitioner and CCS as contributing to HCT readiness, while abstract factors, such as goal-setting and expectations around HCT, were not mentioned. Our results are limited by the dearth of research on this topic, the homogeneity of samples, and joint presentation of CCS and parent data. Nonetheless, our results indicate that parents do not weigh all aspects of SEM equally, with macrolevel barriers, such as sociodemographic factors being viewed as less salient for HCT readiness. Parents mostly focused on interpersonal factors, such as their relationships with practitioners and CCS, indicating that practitioners should emphasize these in preparing parents for HCT.
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Affiliation(s)
- Nele Loecher
- Department of Mental Health Law and Policy, University of South Florida, Tampa, Florida, USA
| | - Jennifer T Tran
- Department of Mental Health Law and Policy, University of South Florida, Tampa, Florida, USA
| | - Kristin Kosyluk
- Department of Mental Health Law and Policy, University of South Florida, Tampa, Florida, USA
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Ji X, Shi KS, Mertens AC, Zhao J, Yabroff KR, Castellino SM, Han X. Survival in Young Adults With Cancer Is Associated With Medicaid Expansion Through the Affordable Care Act. J Clin Oncol 2023; 41:1909-1920. [PMID: 36525612 PMCID: PMC10082236 DOI: 10.1200/jco.22.01742] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 10/26/2022] [Accepted: 11/08/2022] [Indexed: 12/23/2022] Open
Abstract
PURPOSE Medicaid expansion through the Affordable Care Act (ACA) has been shown to improve insurance coverage and early diagnosis of cancer in young adults (YAs); whether these improvements translate to survival benefits remains unknown. We examined the association between Medicaid expansion under the ACA and 2-year overall survival among YAs with cancer. METHODS Using the National Cancer Database, we identified 345,413 YAs (age 18-39 years) diagnosed with cancer in 2010-2017. We applied the difference-in-differences (DD) method to estimate changes in 2-year overall survival after versus before Medicaid expansion in expansion versus nonexpansion states. RESULTS Among all YAs, 2-year overall survival increased more in expansion states (90.39% pre-expansion to 91.85% postexpansion) than in nonexpansion states (88.98% pre-expansion to 90.07% postexpansion), resulting in a net increase of 0.55 percentage points (ppt; 95% CI, 0.13 to 0.96). The expansion-associated survival benefit was concentrated in patients with female breast cancer (DD, 1.20 ppt; 95%CI, 0.27 to 2.12) when stratifying by cancer type and in patients with stage IV disease (DD, 2.56; 95%CI, 0.36 to 4.77) when stratifying by stage. In addition, greater survival benefit associated with Medicaid expansion was observed among racial and ethnic minoritized groups (DD, 1.01 ppt; 95% CI, 0.14 to 1.87) as compared with non-Hispanic White peers (DD, 0.41 ppt; 95% CI, -0.06 to 0.87) and among patients with a Charlson comorbidity score of ≥ 2 (DD, 6.48 ppt; 95% CI, 0.81 to 12.16) than those with a comorbidity score of 0 (DD, 0.44 ppt; 95% CI, 0.005 to 0.87). CONCLUSION Medicaid expansion under the ACA was associated with an improvement in overall survival among YAs with cancer, with survival benefits most pronounced among patients of under-represented race and ethnicity and patients with high-risk diseases.
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Affiliation(s)
- Xu Ji
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
- Aflac Cancer & Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA
| | - Kewei Sylvia Shi
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA
| | - Ann C. Mertens
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
- Aflac Cancer & Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA
| | - Jingxuan Zhao
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA
| | - K. Robin Yabroff
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA
| | - Sharon M. Castellino
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
- Aflac Cancer & Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA
| | - Xuesong Han
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA
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Ji X, Sohn H, Sil S, Castellino SM. Moving Beyond Patient-Level Drivers of Racial/Ethnic Disparities in Childhood Cancer. Cancer Epidemiol Biomarkers Prev 2022; 31:1154-1158. [PMID: 35642393 PMCID: PMC9203027 DOI: 10.1158/1055-9965.epi-21-1068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 11/24/2021] [Accepted: 03/03/2022] [Indexed: 01/11/2023] Open
Abstract
Racial/ethnic disparities in childhood cancer survival persist despite advances in cancer biology and treatment. Survival rates are consistently lower among non-Hispanic Black and Hispanic children as compared with non-Hispanic White children across a range of hematologic cancers and solid tumors. We provide a framework for considering complex systems and social determinants of health in research examining the drivers of racial/ethnic disparities in childhood cancer survival, given that pediatric patients' interactions with the healthcare system are filtered through their caregiver, family, and societal structure. Dismantling the multi-level (patient, family, healthcare system, and structural) barriers into modifiable drivers is critical to developing policies and interventions toward equitable health outcomes. This commentary highlights areas at the family, healthcare system, and society levels that merit closer examination and proposes actions and interventions to support improvements across these levels. See recently published article in the November issue of CEBP, Racial/Ethnic Disparities in Childhood Cancer Survival in the United States p. 2010.
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Affiliation(s)
- Xu Ji
- Department of Pediatrics, Emory University School of
Medicine, Atlanta, Georgia.,Aflac Cancer & Blood Disorders Center,
Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Heeju Sohn
- Department of Sociology, Emory University, Atlanta,
Georgia
| | - Soumitri Sil
- Department of Pediatrics, Emory University School of
Medicine, Atlanta, Georgia.,Aflac Cancer & Blood Disorders Center,
Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Sharon M. Castellino
- Department of Pediatrics, Emory University School of
Medicine, Atlanta, Georgia.,Aflac Cancer & Blood Disorders Center,
Children’s Healthcare of Atlanta, Atlanta, Georgia
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