Self-reported Reasons and Patterns of Noninsurance among Cancer Survivors before and after Implementation of the Affordable Care Act, 2000-2017

Nina N. Sanford, Miranda B. Lam, Santino S. Butler, Chul Ahn, Muhammad S Beg, Ayal A. Aizer, Brandon A. Mahal

Research output: Contribution to journalReview article

Abstract

Importance: Cancer survivors experience difficulties in maintaining health care coverage, but the reasons and risk factors for lack of insurance are poorly defined. Objective: To assess self-reported reasons for not having insurance and demographic and socioeconomic factors associated with uninsured status among cancer survivors, before and after implementation of the Affordable Care Act (ACA) in 2014. Design, Setting, and Participants: This survey study analyzes National Health Interview Survey (NHIS) data from January 1, 2000, through December 31, 2017. Included were adult participants (age, 18-64 years) reporting a cancer diagnosis; however, those with a diagnosis of nonmelanoma skin cancer were excluded. Exposures: Insurance status. Main Outcomes and Measures: Multivariable logistic regression was used to define the association between demographic and socioeconomic variables and odds of being uninsured. The prevalence of the most common self-reported reasons for not having insurance (cost, unemployment, employment-related reason, family-related reason) were estimated, with adjusted odds ratios (aORs) for each of the reasons defined by multivariable logistic regression. Results: Among 17806 survey participants, the mean (SD) age was 50.9 (10.8) years, and 6121 (34.4%) were men. A total of 1842 participants (10.3%) reported not having health insurance. Individuals surveyed in 2000 to 2013 had higher odds of not having insurance than those surveyed in 2014 to 2017 (10.6% vs 6.2%; aOR 1.75; 95% CI 1.49-2.08). Variables associated with higher odds of uninsured status included younger age (14.2% for age younger than mean vs 6.5% for age older than mean; aOR, 1.84; 95%, CI, 1.62-2.10), annual family income below the poverty threshold (21.4% vs 8.0%; aOR, 1.97; 95%, CI, 1.69-2.30), Hispanic ethnicity (18.8% vs 9.0%; aOR, 1.87; 95% CI, 1.51-2.33), noncitizen status (24.3% vs 9.2%; aOR, 2.38; 95% CI, 1.69-3.34), and current smoking (18.6% vs. 6.7%; aOR, 2.65; 95% CI, 2.32-3.02). Before the ACA, increasing interval from cancer diagnosis was associated with not having insurance (12.3% for ≥6 years vs 8.9% for 0-5 years; aOR, 1.47; 95% CI 1.26-1.70) as was black race (13.9% for black patients vs 10.4% for nonblack patients; AOR, 1.29; 95% CI, 1.04-1.61), but after the ACA, they no longer were (6.8% for ≥6 years vs 5.6% for 0-5 years; aOR, 1.12; 95% CI, 0.82-1.54; and 6.9% for black patients vs 6.2% for nonblack patients; aOR, 0.81; 95% CI, 0.46-1.43). The most commonly cited reason for not having insurance was cost, followed by unemployment, both of which decreased after ACA implementation (cost, 49.6% vs 37.6%, aOR [pre-ACA vs post-ACA], 0.62; 95% CI, 0.46-0.85; unemployment, 37.1% vs 28.5%; aOR 0.62; 95% CI, 0.45-0.87). Conclusions and Relevance: The proportion of uninsured cancer survivors decreased after implementation of the ACA, but certain subgroups remained at greater risk of being uninsured. Cost was identified as the primary barrier to obtaining insurance, although more than half of cancer survivors reported other barriers to coverage..

Original languageEnglish (US)
JournalJAMA Oncology
DOIs
StatePublished - Jan 1 2019

Fingerprint

Patient Protection and Affordable Care Act
Insurance
Survivors
Unemployment
Neoplasms
Costs and Cost Analysis
Logistic Models
Demography
Insurance Coverage
Skin Neoplasms
Poverty
Health Insurance
Health Surveys
Hispanic Americans
Smoking
Odds Ratio
Outcome Assessment (Health Care)
Interviews
Delivery of Health Care

ASJC Scopus subject areas

  • Oncology
  • Cancer Research

Cite this

Self-reported Reasons and Patterns of Noninsurance among Cancer Survivors before and after Implementation of the Affordable Care Act, 2000-2017. / Sanford, Nina N.; Lam, Miranda B.; Butler, Santino S.; Ahn, Chul; Beg, Muhammad S; Aizer, Ayal A.; Mahal, Brandon A.

In: JAMA Oncology, 01.01.2019.

Research output: Contribution to journalReview article

@article{0333e57049754ff0886279697f42bf6d,
title = "Self-reported Reasons and Patterns of Noninsurance among Cancer Survivors before and after Implementation of the Affordable Care Act, 2000-2017",
abstract = "Importance: Cancer survivors experience difficulties in maintaining health care coverage, but the reasons and risk factors for lack of insurance are poorly defined. Objective: To assess self-reported reasons for not having insurance and demographic and socioeconomic factors associated with uninsured status among cancer survivors, before and after implementation of the Affordable Care Act (ACA) in 2014. Design, Setting, and Participants: This survey study analyzes National Health Interview Survey (NHIS) data from January 1, 2000, through December 31, 2017. Included were adult participants (age, 18-64 years) reporting a cancer diagnosis; however, those with a diagnosis of nonmelanoma skin cancer were excluded. Exposures: Insurance status. Main Outcomes and Measures: Multivariable logistic regression was used to define the association between demographic and socioeconomic variables and odds of being uninsured. The prevalence of the most common self-reported reasons for not having insurance (cost, unemployment, employment-related reason, family-related reason) were estimated, with adjusted odds ratios (aORs) for each of the reasons defined by multivariable logistic regression. Results: Among 17806 survey participants, the mean (SD) age was 50.9 (10.8) years, and 6121 (34.4{\%}) were men. A total of 1842 participants (10.3{\%}) reported not having health insurance. Individuals surveyed in 2000 to 2013 had higher odds of not having insurance than those surveyed in 2014 to 2017 (10.6{\%} vs 6.2{\%}; aOR 1.75; 95{\%} CI 1.49-2.08). Variables associated with higher odds of uninsured status included younger age (14.2{\%} for age younger than mean vs 6.5{\%} for age older than mean; aOR, 1.84; 95{\%}, CI, 1.62-2.10), annual family income below the poverty threshold (21.4{\%} vs 8.0{\%}; aOR, 1.97; 95{\%}, CI, 1.69-2.30), Hispanic ethnicity (18.8{\%} vs 9.0{\%}; aOR, 1.87; 95{\%} CI, 1.51-2.33), noncitizen status (24.3{\%} vs 9.2{\%}; aOR, 2.38; 95{\%} CI, 1.69-3.34), and current smoking (18.6{\%} vs. 6.7{\%}; aOR, 2.65; 95{\%} CI, 2.32-3.02). Before the ACA, increasing interval from cancer diagnosis was associated with not having insurance (12.3{\%} for ≥6 years vs 8.9{\%} for 0-5 years; aOR, 1.47; 95{\%} CI 1.26-1.70) as was black race (13.9{\%} for black patients vs 10.4{\%} for nonblack patients; AOR, 1.29; 95{\%} CI, 1.04-1.61), but after the ACA, they no longer were (6.8{\%} for ≥6 years vs 5.6{\%} for 0-5 years; aOR, 1.12; 95{\%} CI, 0.82-1.54; and 6.9{\%} for black patients vs 6.2{\%} for nonblack patients; aOR, 0.81; 95{\%} CI, 0.46-1.43). The most commonly cited reason for not having insurance was cost, followed by unemployment, both of which decreased after ACA implementation (cost, 49.6{\%} vs 37.6{\%}, aOR [pre-ACA vs post-ACA], 0.62; 95{\%} CI, 0.46-0.85; unemployment, 37.1{\%} vs 28.5{\%}; aOR 0.62; 95{\%} CI, 0.45-0.87). Conclusions and Relevance: The proportion of uninsured cancer survivors decreased after implementation of the ACA, but certain subgroups remained at greater risk of being uninsured. Cost was identified as the primary barrier to obtaining insurance, although more than half of cancer survivors reported other barriers to coverage..",
author = "Sanford, {Nina N.} and Lam, {Miranda B.} and Butler, {Santino S.} and Chul Ahn and Beg, {Muhammad S} and Aizer, {Ayal A.} and Mahal, {Brandon A.}",
year = "2019",
month = "1",
day = "1",
doi = "10.1001/jamaoncol.2019.1973",
language = "English (US)",
journal = "JAMA oncology",
issn = "2374-2437",
publisher = "American Medical Association",

}

TY - JOUR

T1 - Self-reported Reasons and Patterns of Noninsurance among Cancer Survivors before and after Implementation of the Affordable Care Act, 2000-2017

AU - Sanford, Nina N.

AU - Lam, Miranda B.

AU - Butler, Santino S.

AU - Ahn, Chul

AU - Beg, Muhammad S

AU - Aizer, Ayal A.

AU - Mahal, Brandon A.

PY - 2019/1/1

Y1 - 2019/1/1

N2 - Importance: Cancer survivors experience difficulties in maintaining health care coverage, but the reasons and risk factors for lack of insurance are poorly defined. Objective: To assess self-reported reasons for not having insurance and demographic and socioeconomic factors associated with uninsured status among cancer survivors, before and after implementation of the Affordable Care Act (ACA) in 2014. Design, Setting, and Participants: This survey study analyzes National Health Interview Survey (NHIS) data from January 1, 2000, through December 31, 2017. Included were adult participants (age, 18-64 years) reporting a cancer diagnosis; however, those with a diagnosis of nonmelanoma skin cancer were excluded. Exposures: Insurance status. Main Outcomes and Measures: Multivariable logistic regression was used to define the association between demographic and socioeconomic variables and odds of being uninsured. The prevalence of the most common self-reported reasons for not having insurance (cost, unemployment, employment-related reason, family-related reason) were estimated, with adjusted odds ratios (aORs) for each of the reasons defined by multivariable logistic regression. Results: Among 17806 survey participants, the mean (SD) age was 50.9 (10.8) years, and 6121 (34.4%) were men. A total of 1842 participants (10.3%) reported not having health insurance. Individuals surveyed in 2000 to 2013 had higher odds of not having insurance than those surveyed in 2014 to 2017 (10.6% vs 6.2%; aOR 1.75; 95% CI 1.49-2.08). Variables associated with higher odds of uninsured status included younger age (14.2% for age younger than mean vs 6.5% for age older than mean; aOR, 1.84; 95%, CI, 1.62-2.10), annual family income below the poverty threshold (21.4% vs 8.0%; aOR, 1.97; 95%, CI, 1.69-2.30), Hispanic ethnicity (18.8% vs 9.0%; aOR, 1.87; 95% CI, 1.51-2.33), noncitizen status (24.3% vs 9.2%; aOR, 2.38; 95% CI, 1.69-3.34), and current smoking (18.6% vs. 6.7%; aOR, 2.65; 95% CI, 2.32-3.02). Before the ACA, increasing interval from cancer diagnosis was associated with not having insurance (12.3% for ≥6 years vs 8.9% for 0-5 years; aOR, 1.47; 95% CI 1.26-1.70) as was black race (13.9% for black patients vs 10.4% for nonblack patients; AOR, 1.29; 95% CI, 1.04-1.61), but after the ACA, they no longer were (6.8% for ≥6 years vs 5.6% for 0-5 years; aOR, 1.12; 95% CI, 0.82-1.54; and 6.9% for black patients vs 6.2% for nonblack patients; aOR, 0.81; 95% CI, 0.46-1.43). The most commonly cited reason for not having insurance was cost, followed by unemployment, both of which decreased after ACA implementation (cost, 49.6% vs 37.6%, aOR [pre-ACA vs post-ACA], 0.62; 95% CI, 0.46-0.85; unemployment, 37.1% vs 28.5%; aOR 0.62; 95% CI, 0.45-0.87). Conclusions and Relevance: The proportion of uninsured cancer survivors decreased after implementation of the ACA, but certain subgroups remained at greater risk of being uninsured. Cost was identified as the primary barrier to obtaining insurance, although more than half of cancer survivors reported other barriers to coverage..

AB - Importance: Cancer survivors experience difficulties in maintaining health care coverage, but the reasons and risk factors for lack of insurance are poorly defined. Objective: To assess self-reported reasons for not having insurance and demographic and socioeconomic factors associated with uninsured status among cancer survivors, before and after implementation of the Affordable Care Act (ACA) in 2014. Design, Setting, and Participants: This survey study analyzes National Health Interview Survey (NHIS) data from January 1, 2000, through December 31, 2017. Included were adult participants (age, 18-64 years) reporting a cancer diagnosis; however, those with a diagnosis of nonmelanoma skin cancer were excluded. Exposures: Insurance status. Main Outcomes and Measures: Multivariable logistic regression was used to define the association between demographic and socioeconomic variables and odds of being uninsured. The prevalence of the most common self-reported reasons for not having insurance (cost, unemployment, employment-related reason, family-related reason) were estimated, with adjusted odds ratios (aORs) for each of the reasons defined by multivariable logistic regression. Results: Among 17806 survey participants, the mean (SD) age was 50.9 (10.8) years, and 6121 (34.4%) were men. A total of 1842 participants (10.3%) reported not having health insurance. Individuals surveyed in 2000 to 2013 had higher odds of not having insurance than those surveyed in 2014 to 2017 (10.6% vs 6.2%; aOR 1.75; 95% CI 1.49-2.08). Variables associated with higher odds of uninsured status included younger age (14.2% for age younger than mean vs 6.5% for age older than mean; aOR, 1.84; 95%, CI, 1.62-2.10), annual family income below the poverty threshold (21.4% vs 8.0%; aOR, 1.97; 95%, CI, 1.69-2.30), Hispanic ethnicity (18.8% vs 9.0%; aOR, 1.87; 95% CI, 1.51-2.33), noncitizen status (24.3% vs 9.2%; aOR, 2.38; 95% CI, 1.69-3.34), and current smoking (18.6% vs. 6.7%; aOR, 2.65; 95% CI, 2.32-3.02). Before the ACA, increasing interval from cancer diagnosis was associated with not having insurance (12.3% for ≥6 years vs 8.9% for 0-5 years; aOR, 1.47; 95% CI 1.26-1.70) as was black race (13.9% for black patients vs 10.4% for nonblack patients; AOR, 1.29; 95% CI, 1.04-1.61), but after the ACA, they no longer were (6.8% for ≥6 years vs 5.6% for 0-5 years; aOR, 1.12; 95% CI, 0.82-1.54; and 6.9% for black patients vs 6.2% for nonblack patients; aOR, 0.81; 95% CI, 0.46-1.43). The most commonly cited reason for not having insurance was cost, followed by unemployment, both of which decreased after ACA implementation (cost, 49.6% vs 37.6%, aOR [pre-ACA vs post-ACA], 0.62; 95% CI, 0.46-0.85; unemployment, 37.1% vs 28.5%; aOR 0.62; 95% CI, 0.45-0.87). Conclusions and Relevance: The proportion of uninsured cancer survivors decreased after implementation of the ACA, but certain subgroups remained at greater risk of being uninsured. Cost was identified as the primary barrier to obtaining insurance, although more than half of cancer survivors reported other barriers to coverage..

UR - http://www.scopus.com/inward/record.url?scp=85065866686&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85065866686&partnerID=8YFLogxK

U2 - 10.1001/jamaoncol.2019.1973

DO - 10.1001/jamaoncol.2019.1973

M3 - Review article

JO - JAMA oncology

JF - JAMA oncology

SN - 2374-2437

ER -