Center for Healthcare Policy & Research, University of California Davis, Sacramento, California, USA.
Center for Oncology Hematology Outcomes Research and Training (COHORT), University of California Davis Comprehensive Cancer Center, Sacramento, California, USA.
Int J Cancer. 2022 Apr 1;150(7):1113-1122. doi: 10.1002/ijc.33880. Epub 2021 Dec 8.
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.
青少年和年轻人（15-39 岁）是美国最大的未参保人群，这增加了他们癌症晚期诊断和生存不良的可能性。我们评估了平价医疗法案（ACA）、保险覆盖范围、诊断时的分期和生存之间的关联，研究对象为患有原发性非霍奇金淋巴瘤（NHL；n=5959）或霍奇金淋巴瘤（n=5378）的 AYA 患者。我们使用了加利福尼亚癌症登记处的数据，并与 AYA 患者在 ACA 早期和全面实施时期的医疗补助参保档案进行了链接。医疗保险分为连续医疗补助、不连续医疗补助、诊断时的医疗补助登记/无保险、其他公共和私人保险。我们使用多变量回归模型进行统计分析。在 ACA 全面实施之前，未参保/入保的 AYA 患者比例从 13.4%下降到 9.7%，而在此期间，连续医疗补助的比例从 9.3%上升到 29.6%（P<.001）。在 ACA 全面实施后，患有 NHL 的 AYA 患者被诊断为 IV 期疾病的可能性较小（调整后的优势比[aOR]为 0.84，95%置信区间[CI]为 0.73-0.97）。患有淋巴瘤的 AYA 患者更有可能在国家癌症研究所指定的癌症中心接受治疗（调整后的优势比[aOR]为 1.42，95%置信区间[CI]为 1.28-1.57），并且在 ACA 全面实施后，死亡的可能性更低（调整后的危险比[HR]为 0.54，95%置信区间[CI]为 0.46-0.63）。然而，来自社会经济地位最低的社区、少数族裔群体和使用医疗补助的 AYA 患者的生存情况仍然较差。总之，在 ACA 下，医疗补助的扩大使患有淋巴瘤的 AYA 患者获得了更多的医疗保健，并取得了更好的临床结果。然而，社会经济和种族/族裔差异仍然存在，需要进一步努力减少服务不足的患有淋巴瘤的 AYA 中的健康不平等现象。
