ACA Dependent Coverage & Young Adults with Cancer
As the Supreme Court mulls yet another challenge to the constitutionality of the Affordable Care Act (ACA), we have new evidence of the law’s positive impact on young adults, who were allowed to stay on their parents’ insurance until age 26 under the Dependent Coverage Provision (DCP). The ACA helped young adults with cancer maintain continuous coverage, which is key to maintaining access to cancer treatment.
In a recent retrospective cohort study, my colleagues and I found that cancer patients who turned 19 in 2010–2012 (who were eligible to stay on their parents’ insurance) were 15% less likely to lose coverage than those who turned 19 in 2007–2009, before the ACA. We used commercial claims data to identify about 2,800 young adults with a cancer diagnosis between 2000 and 2015, and compared them to their peers prior to the ACA’s implementation. We matched the two groups on cancer type, diagnosis date, and clinical characteristics, and compared time to loss of insurance over 5 years.
While disruptions in coverage may be a nuisance for healthy enrollees, they can be catastrophic for young adults with cancer or a history of cancer. Studies have linked missing chemotherapy doses to cancer recurrence. A recent case provides an important example of the impact of coverage disruptions on this population. I recall a 21-year-old patient who moved to California in the middle of his treatment for recurrent leukemia. He was previously insured, but due to his recent move, he was unemployed and uninsured. He needed oral chemotherapy and he was only able to receive these lifesaving medications through admission to the hospital. If this young man had been on his parents’ insurance, he could have easily received these medications from an outpatient pharmacy regardless of his recent move.
Our patient’s case highlights many of the reasons that the DCP’s impact on coverage disruptions is so important. Young adults are inherently in a transitional period in their lives: they are often living outside their parents’ home for the first time, going off to college, or getting their first full time job. They are learning how to navigate the world and manage their own health (and health insurance). With all of these big life changes, young adults often have difficulty adhering to their essential cancer-directed medications and are more likely to experience gaps in insurance coverage.
Previous research has shown that rates of uninsurance among cancer patients have improved under the ACA. The DCP provides a critical mechanism for unemployed young adults with cancer to obtain insurance through their parents. It is even more essential at this time when the coronavirus pandemic has led to record job loss and loss of employer health insurance among young adults. However, the ACA is once again under threat. A recent case argued before the Supreme Court on November 10, 2020 challenges the constitutionality of the ACA’s individual mandate. Now that the mandate is no longer associated with any financial penalty, the plaintiffs argue that the ACA cannot be covered under Congress’s power to tax, and thus that the entire law is invalid.
Our study has several important implications. First, there must be increased efforts to educate young adults and their families about the DCP, which provides critical protections for young adults with complex and chronic illnesses. Research suggests that less than 1 in 6 young adults with a history of cancer are familiar with the DCP option. Second, while experts project that the rest of the ACA is likely to stand if the mandate falls, continued threats to the ACA (and hence, the DCP) could lead to abrupt disruptions in continuous insurance coverage. These coverage losses could have potentially dire consequences for young adults with cancer and young adult cancer survivors.
Finally, to our knowledge, this is the first study to examine the impact of the DCP on insurance continuity for young adults with cancer. Recent evidence has linked the DCP to more timely receipt of chemotherapy in colorectal cancer. Future studies should examine how improvements in insurance continuity affect access to and receipt of care for other more common cancer diagnoses in the young adult population.
The study, Impact of Dependent Coverage Provision of the Affordable Care Act on Insurance Continuity for Adolescents and Young Adults With Cancer, was first published online in JCO Oncology Practice in October 2020. Authors include Lena E. Winestone, Lauren L. Hochman, James E. Sharpe, Elysia Alvarez, Laura Becker, Eric J. Chow, Joseph G. Reiter, Jill P. Ginsberg, and Jeffrey H. Silber.