Financial and Clinical Outcomes among Commercially-Insured Cancer Patients following the Affordable Care Act

Project Summary/Abstract Demographic changes in the commercially insured population following implementation of the Affordable Care Act (ACA)—specifically improved enrollment of the near-poor and those with chronic comorbidities--may have paradoxically magnified the problem of “underinsurance;” that is, insurance that leaves persons at high risk for financial hardship and care gaps following illness. The central objective for this study is to understand the extent to which commercially insured cancer patients are at risk for shortfalls in care and adverse financial outcomes. Our working hypothesis is that underinsurance is causing gaps in care and financial hardship for a substantial proportion of cancer patients with commercial insurance in the post-ACA era. To address our objective and hypothesis, we will utilize a novel person-linked, population-level database that includes: 1) Western WA SEER cancer registry data for cancer patients diagnosed in 2009-2022; 2) WA state voter registration file data (non-cancer controls); 3) Enrollment and claims records from the state’s largest commercial payers (Regence Blue Shield and Premera Blue Cross); 4) Longitudinal financial and credit records from TransUnion; 5) Washington State bankruptcy records and 6) Medicaid enrollment records. Using this unique database that is updated annually, our first aim is to understand how the neighborhood characteristics, financial health, and clinical characteristics of commercially insured cancer patients have changed following ACA implementation. Due to expanded eligibility for commercial insurance under the ACA, we hypothesize that a greater proportion of cancer patients diagnosed post-ACA (2015-2022) live in disadvantaged neighborhoods, are financially fragile (lower credit, higher debt, delinquent payments), and have more comorbidities than pre-ACA (2009-2012) patients. Our second aim is to estimate post-ACA trends in out-of-pocket (OOP) cost exposure and underinsurance. We will characterize trends and variability in OOP exposure and risk of underinsurance for cancer patients across employer-based and ACA marketplace plans. Our third aim is to determine the extent to which commercially insured, cancer patients diagnosed after implementation of the ACA experience gaps in care and adverse cancer outcomes. In addition, we will measure the relationship between OOP cost exposure and adverse outcomes for these patients, defined as gaps in quality of care, financial hardship, and disenrollment from commercial insurance and/or enrollment in Medicaid following diagnosis. This unique study and ongoing collaboration with an external, community-based multi-stakeholder advisory group will provide crucial evidence to inform clinical and policy discussions aimed at identifying and reducing treatment gaps and adverse outcomes among commercially insured cancer patients in the post-ACA era.