Health insurance and cancer care in the era of effective high-cost new treatments: what are the effects of policy interventions? Restricted; Files Only
Zhao, Jingxuan (Summer 2024)
Abstract
Introduction
Health insurance is a strong predictor of access to care and health outcomes in the United States. A substantial body of research has demonstrated that among newly diagnosed cancer patients, individuals who were uninsured were more likely to be diagnosed with late-stage disease and have worse survival, and less likely to receive guideline-concordant care compared to individuals with private health insurance coverage. As health insurance is a modifiable factor and can be affected by health policies, understanding health insurance and access to cancer treatment and cancer outcomes can inform policymakers’ decision making, which may in turn reduce cancer disparities. In Chapter 1, we examined if the introduction of immune checkpoint inhibitors (ICIs), a high-cost effective immunotherapy, can unintentionally contribute to growth in and/or slow elimination of disparities in overall survival among cancer patients. In Chapter 2, we examined Medicaid expansion under the Affordable Care Act, can improve access to cancer care across cancer control continuum among non-small cell lung cancer (NSCLC) patients. In Chapter 3, we examined if lack of state policy regulation on short-term limited duration (STLD) plans is associated with delay in access to cancer treatment.
Methods
We identified patients newly diagnosed with cancer from the National Cancer Database from all three chapters. In Chapter 1, we compared survival in individuals newly diagnosed at age 18-64 years at stage IV with any one of the following cancers with the US Food and Drug Administration approval for ICI treatment, including melanoma, hormone receptor-positive, human epidermal growth factor receptor 2 negative female breast cancer, NSCLC, and renal cell carcinoma (RCC) before and after FDA approval of ICIs. Patients with private health insurance or who were uninsured at the time of the cancer diagnosis were included. In Chapter 2, we examined the association of Medicaid expansion and (1) stage at disease diagnosis, (2) timely treatment initiation, (3) guideline-concordant treatment, and (4) five-year survival. In Chapter 3, patients were categorized into 5 groups based on their state of residence at diagnosis: (1) state continuously prohibited STLD plans; (2) state stopped offering STLD plans after the 2018 federal rule; (3) state kept the same 3-month limit on STLD plans before and after the 2018 federal rule; (4) state expanded the sale of STLD plans but imposed more stringent regulations on STLD plans in addition to the 2018 federal rules, and (5) state expanded the sale of STLD plans and did not impose additional regulation beyond the 2018 federal rule. A difference-in-differences approach was used in all three chapters.
Results
In Chapter 1, we found that the introduction of ICIs increased disparities in survival by health insurance status among patients diagnosed with stage IV melanoma, NSCLC, or RCC. In Chapter 2, we found that Medicaid expansion was associated with increases in early-stage diagnosis and increases in timely treatment initiation and survival among newly diagnosed NSCLC patients. In Chapter 3, we found that limited or no state regulation of STLD plans after the 2018 federal expansion of plan coverage duration was associated with decreases in timely treatment initiation.
Conclusions
In summary, findings from all the three chapters indicated that policies to improve and regulate health insurance coverage and to make new treatments more affordable are needed.
Table of Contents
Introduction………………………………………………………………………………………1
Background……………………………………………………………………….…..…………1
Dissertation Chapters…………………………………………………………….…....….…4
References……………………………………………………………………………...….……5
Chapter 1…………………………...……………………….……………………………….……7
Abstract…………………………...……………………….………………………...……….…8
Introduction...…………………………………………………………………….….….......10
Methods...…………………………………………………......………………….….….......11
Results...…………………………………………………......………………….……..........16
Discussion...…………………………….….……………......………………….…….........18
Conclusions...…………………………………………………......…………………..….....21
References...…………………………………………………......………………….…….....22
Tables and Figures...………....………………………………......………………….…….24
Supplement...…………………………………………………......……………….….........29
Chapter 2.…………………………...……………………….…………………………...…....35
Abstract…………………………...……………………….……...……….………...……....36
Introduction...…………………………………………………………………….….……....37
Methods...…………………………………………………......…………………..………....39
Results...…………………………………………………......………………….……...…....45
Discussion...……………………………..………………......………………….……...…...49
Conclusions...…………………………………………………......………………….……...52
References...…………………………………………………......………………….…….....53
Tables and Figures...………....………………………………......………………….……..56
Supplement...…………………………………………………......……………….….……..63
Chapter 3…………………………...……………………….…………………………...……...82
Abstract…………………………...……………………….………………………...…….…..83
Introduction...…………………………………………………………………….….…….....84
Methods...…………………………………………………......…………………..……….....88
Results...…………………………………………………......………………….……...….....91
Discussion...…………………………….….……………......………………….……...…....93
Conclusions...…………………………………………………......………………….……....96
References...…………………………………………………......………………….……......98
Tables and Figures...………....………………………………......………………….…....101
Supplement...…………………………………………………......……………….….….....109
Conclusions……………………………………………………………………………….….…126
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