Stage at diagnosis and survival among adolescents and young adults with lymphomas following the Affordable Care Act implementation in California

Abstract

Adolescents and young adults (AYAs, 15‐39 years) are the largest uninsured population in the Unites States, increasing the likelihood of late‐stage cancer diagnosis and poor survival. We evaluated the associations between the Affordable Care Act (ACA), insurance coverage, stage at diagnosis and survival among AYAs with lymphoma. We used data from the California Cancer Registry linked to Medicaid enrollment files on AYAs diagnosed with a primary non‐Hodgkin (NHL; n = 5959) or Hodgkin (n = 5378) lymphoma pre‐ACA and in the early and full ACA eras. Health insurance was categorized as continuous Medicaid, discontinuous Medicaid, Medicaid enrollment at diagnosis/uninsurance, other public and private. We used multivariable regression models for statistical analyses. The proportion of AYAs uninsured/Medicaid enrolled at diagnosis decreased from 13.4% pre‐ACA to 9.7% with full ACA implementation, while continuous Medicaid increased from 9.3% to 29.6% during this time (P < .001). After full ACA, AYAs with NHL were less likely to be diagnosed with Stage IV disease (adjusted odds ratio [aOR] = 0.84, 95% confidence interval [CI] = 0.73‐0.97). AYAs with lymphoma were more likely to receive care at National Cancer Institute‐Designated Cancer Centers (aOR = 1.42, 95% CI = 1.28‐1.57) and had lower likelihood of death (adjusted hazard ratio = 0.54, 95% CI = 0.46‐0.63) after full ACA. However, AYAs from the lowest socioeconomic neighborhoods, racial/ethnic minority groups and those with Medicaid continued to experience worse survival. In summary, AYAs with lymphomas experienced increased access to healthcare and better clinical outcomes following Medicaid expansion under the ACA. Yet, socioeconomic and racial/ethnic disparities remain, calling for additional efforts to decrease health inequities among underserved AYAs with lymphoma.

Environmental pesticide exposure and non-Hodgkin lymphoma survival: a population-based study

“…Models considered five common types of pesticide (glyphosate, organophosphorus, carbamate, phenoxyherbicide, and 2,4-dimethylamine salt) and NHL subtype separately. Models included variables with a priori reasons for inclusion based on previous studies: gender, race/ethnicity, age and stage at diagnosis, modality of initial therapy, health insurance status, neighborhood SES and rural or urban MSSA [ 36 – 38 ]. We also examined whether associations between pesticide exposure and survival differed by race/ethnicity in multivariable Cox models performed separately in Hispanic/Latino, non-Hispanic white, Asian/Pacific Islander, and African American patients.…”

Classic Hodgkin Lymphoma in Adolescents and Young Adults

“…71 Better outcomes were observed after expansion of insurance coverage through the Affordable Care Act, although persistent disparities are observed for AYAs with HL of Black race, low socioeconomic status, and older age. 72 Delivery of appropriate therapy was observed in 58% of AYAs with HL, with lower rates observed among patients receiving care at non-National Cancer Institute (NCI)-affiliated cancer centers compared with NCI-designated cancer centers, academic institutions, or community hospitals. 73 Clinical trial participation by AYAs is increasing, although less so for AYAs with HL.…”

Cost of Cancer in Adolescents and Young Adults in the United States: Results of the 2021 Report by Deloitte Access Economics, Commissioned by Teen Cancer America

“…Furthermore, changes in types of employers and generosity of benefits over the past couple of decades affect current AYAs who may be more likely to be gig economy workers or to work in positions without benefits. The passage of the Patient Protection and Affordable Care Act (ACA) has three important provisions that were critical for AYAs: (1) the Dependent Coverage Expansion with extended coverage under parents' private insurance until 26 years; (2) elimination of the ability to deny coverage or charge more or due to a preexisting condition; and (3) increased access to insurance through Medicaid expansion in some states and creation of health insurance exchanges (Marketplace) [24][25][26][27][28][29][30] for individual purchase with premium subsidies. Among those states that elected to expand Medicaid income eligibility to residents, there has been an increase in insurance coverage and detection of early-stage cancer (v late stage) among AYAs.…”