Financial barriers fell for some cancer survivors after Affordable Care Act

Younger cancer survivors — those between ages 18 and 64 — faced fewer financial barriers to health care after the Affordable Care Act was implemented than they did before the landmark law took effect. This is one of the findings from a new paper in JCO Oncology Practice.

In fact, the study's authors — who include Susan Goold, M.D., M.H.S.A., M.A., senior author, and Christopher Su, M.D., first author —  believe the ACA helped the financial burden (problems related to the cost of medical care) for younger cancer survivors fall to its lowest estimated levels in 20 years.

“There has been a lot of talk about the ACA affecting people who don’t have the Medicare safety net,” said Su, a clinical fellow in the division of hematology and oncology at Michigan Medicine. “We were able to drill down to that and show that it did make a difference to younger cancer survivors.”

Su and the team analyzed data from more than 20,000 Americans who responded to the National Health Interview Survey, a long-running series of interviews conducted by a part of the Centers for Disease Control and Prevention that collects data on everything from chronic conditions to vaccinations.

They found that the younger group of cancer survivors were less likely to delay treatment because of cost and didn’t have as much trouble paying for medications or dental care from 2014 to 2018. This was the five-year period after several key features of the ACA — including the Health Insurance Marketplace, through which individuals, families and small businesses can compare and purchase health insurance plans — went into effect.

In contrast, cancer survivors 65 and older didn’t experience much of a change in their ability to afford health care post-ACA, likely because so many were on Medicare.

“When the major provisions of the Affordable Care Act came into play, all the measures of affordability came down for the younger survivors,” Su said, “but they actually stayed the same for the Medicare population.”

When the researchers traced these measures back over the past two decades, they saw that, between 2015 and 2017, all had dropped to their lowest points since 1999 for adult cancer survivors younger than 65. Essentially, younger cancer survivors were more likely to be able to afford their health care than at any other time since the 21st century began.

“At the end of the day, the ACA really benefits people who are vulnerable,” Su said, “who are at high risk, who, for whatever reason, need to come to get medical care a lot and the medical care that they get is expensive. I think we can say that cancer patients fit this definition.”

More insurance for younger survivors

In addition, the number of younger cancer survivors without health insurance dropped and Medicaid enrollment for this group increased after the ACA became law.

Given the ACA’s expansion of eligibility for Medicaid — the United States’ public health insurance program for those with a low income or a disability and/or who are elderly — and its requirement that the majority of Americans buy health insurance or pay a penalty, these findings aren’t surprising, Su said. (Starting in 2019, people are no longer fined if they don’t purchase health insurance, but that change took place after the period from which researchers analyzed data.)

Yet the results do point to another way that the ACA has helped adult cancer survivors younger than 65, who often rely on their jobs for health insurance and can face difficult decisions when they’re not able to work because of illness and long-term treatment.

“The younger working population doesn’t have pensions,” Su said. “Most don’t have a rainy-day fund stored away for them if they get cancer. They’re still trying to work, still trying to put bread on the table. But the ACA made it easier to sign up for Medicaid, to sign up for a health insurance plan that’s affordable to them, and now they have a better umbrella to fall back on for their health care expenses without jeopardizing their already precarious finances because cancer put them out of work or reduced the time that they could be working.”

“I think it made a tremendous difference,” he added.

The source of the improvement

The spike in Medicaid enrollment for younger cancer survivors also prompted Su and his team to wonder whether Medicaid expansion was driving the drop in financial barriers for this population.

Ideally, they would have been able to compare younger cancer survivors in states that had expanded Medicaid versus those that had not. Although the National Health Interview Survey does not break its data down by state, the researchers were able to use regions where the majority of states had expanded Medicaid, including the West and Northeast, and those that had been more resistant to Medicaid expansion, like the South, as proxies.

The analysis didn’t turn up many differences, leading Su et al. to conclude that other aspects of the ACA had played just as much of a role in decreasing financial barriers for younger cancer survivors as Medicaid expansion.

“We found that within geographic regions, the numbers are similar, which argues more strongly to the ACA having a very comprehensive impact,” Su said. “Things like the employer mandate [which required all companies of a certain size to provide health insurance for their employees] and establishing the health care exchanges that made it easier for people to get insurance — all of these things incrementally played a difference in the health care of the cancer survivors.”

Paper cited: “Affordable Care Act and Cancer Survivors’ Financial Barriers to Care: Analysis of the National Health Interview Survey, 2009-2018,” JCO Oncology Practice. DOI: 10.1200/OP.21.00095