Socioeconomic and Demographic Variation in Insurance Coverage Among Patients With Head and Neck Cancer After the Affordable Care Act

JAMA Otolaryngol Head Neck Surg. 2019 Dec 1;145(12):1144-1149. doi: 10.1001/jamaoto.2019.2724.


Importance: Health insurance status has a significant association with early diagnosis and stage at presentation, which are the most important predictors of survival among patients with head and neck cancer (HNC). Literature on the association of the Patient Protection and Affordable Care Act (ACA) with changes in insurance status among patients with HNC remains limited. To our knowledge, no studies have evaluated changes in insurance rates across sociodemographic subgroups of patients with HNC.

Objective: To assess the association of the implementation of the ACA with insurance status across socioeconomic and demographic subpopulations of patients with HNC.

Design, setting, and participants: A retrospective cohort study using data from the National Cancer Database (NCDB), a hospital-based cancer registry (2011-2015) for adults diagnosed with a malignant primary HNC was carried out. The analyses were conducted from November 2018 through December 2018.

Main outcomes and measures: Changes in the percentage of patients with insurance.

Results: A total of 131 779 patients with HNC were identified in the pre-ACA (77 071) and post-ACA (54 708) periods. Overall, 98 207 (74.5%) participants were men and 33 572 (25.5) were women, with 73 124 (55.5%) being aged between 50 to 64 years. There was a 2.68 percentage point decrease (PPD) (95% CI, 2.93-2.42) in the percentage of patients with HNC without insurance from the pre-ACA to the post-ACA period. Changes in the percentage of uninsured patients varied significantly by age, with the largest reduction in uninsured status among patients with HNC aged 18 to 34 years (5.12 PPD; 95% CI, 3.18-7.06) and the smallest reduction in uninsured among those aged 65 to 74 years (0.24 PPD; 95% CI, 0.03-0.45). There was a significantly greater reduction in uninsured status in low-income zip codes (3.45 PPD; 95% CI, 2.76-4.14) than in high-income zip codes (1.99 PPD; 95% CI, 1.63-2.36).

Conclusions and relevance: There was a significant association between ACA implementation and percentage decrease in uninsured patients. Young adults and those residing in low-income zip codes experienced a significantly higher rate of insurance uptake compared with older adults and residents of high-income areas. This suggests that coverage expansions enacted through the ACA are not only associated with increased access to care among the broader HNC population, but that they may also yield a greater benefit among subpopulations with historically limited insurance coverage.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Databases, Factual
  • Female
  • Head and Neck Neoplasms / diagnosis
  • Head and Neck Neoplasms / economics*
  • Head and Neck Neoplasms / therapy
  • Health Services Accessibility / economics
  • Health Services Accessibility / legislation & jurisprudence
  • Health Services Accessibility / trends*
  • Humans
  • Insurance Coverage / legislation & jurisprudence
  • Insurance Coverage / trends*
  • Insurance, Health / legislation & jurisprudence
  • Insurance, Health / trends*
  • Linear Models
  • Male
  • Medically Uninsured / legislation & jurisprudence
  • Medically Uninsured / statistics & numerical data*
  • Middle Aged
  • Patient Protection and Affordable Care Act*
  • Registries
  • Retrospective Studies
  • Socioeconomic Factors*
  • United States
  • Young Adult