Yang Nuo Nova, Zhao Jingxuan, Barnes Justin M, Kirchhoff Anne C, Chino Fumiko, Yabroff K Robin, Han Xuesong
Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia.
Department of Radiation Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri.
JAMA Netw Open. 2025 Mar 3;8(3):e251075. doi: 10.1001/jamanetworkopen.2025.1075.
Many short-term limited duration (STLD) insurance plans do not cover essential health benefits, such as cancer screenings, potentially delaying diagnoses. In October 2018, federal regulations loosened restrictions on STLD plans by extending the allowable duration from 3 months to 36 months. States expanded, restricted, or eliminated the sale or terms of STLD plans, both prior to 2018 and afterwards. The association of state-level policies and late-stage cancer diagnosis is largely undocumented.
To examine associations of state-level policies regarding STLD plans and late-stage cancer diagnosis before and after the 2018 federal rule.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study included adults aged 18 to 64 years newly diagnosed with cancer (January 2016 to February 2020) in 47 states and the District of Columbia from the National Cancer Database. Patients were grouped by state-level STLD plan policies: (1) states continuously prohibited STLD plans before and after 2018; (2) states stopped offering STLD plans after 2018; (3) states allowed the sale of STLD plans with additional restrictions to the 2018 federal rules; (4) states with no additional STLD regulation. Difference-in-differences analyses were conducted to evaluate changes in late-stage diagnoses (stages III/IV) pre-2018 (January 2016 to June 2018) and post-2018 (January 2019 to February 2020) for groups 2, 3, and 4 vs group 1 for all cancers combined and for 5 common cancers, adjusting for sociodemographic factors (age group, sex, metropolitan status, zip code-level poverty), diagnosis year, and state random effect. All analyses were performed from May 2023 to January 2025.
State-level STLD plan policies.
Change in percentages of late-stage cancer diagnosis.
Among 1 289 366 adults newly diagnosed with cancer (mean [SD] age, 53 [9.2] years; 536 514 [41.6%] female; 73 061 [5.7%] Hispanic, 110 564 [8.6%] non-Hispanic Asian and Pacific Islander and other, 172 246 [13.4%] non-Hispanic Black, 921 722 [71.5%] non-Hispanic White), 604 882 (46.9%) were from group 4 states (no additional STLD regulations). Group 4 had a net increase of 0.76 (95% CI, 0.22-1.29) percentage points (P = .01) and group 3 (some STLD regulations) had a net increase of 0.84 (95% CI, 0.26-1.42) percentage points (P = .005) in late-stage diagnoses compared with group 1 (continuously prohibited STLD plans). Similar patterns were observed for female breast and colorectal cancers.
In this cross-sectional study of state-level policies regarding STLD plans and late-stage cancer diagnosis, loosened federal restrictions on STLD plans in 2018 were associated with a net increase in late-stage cancer diagnoses in states without or with inadequate regulatory protections, underscoring the critical role of state policies in regulating STLD plans.
许多短期限期（STLD）保险计划不涵盖诸如癌症筛查等基本健康福利，这可能会延迟诊断。2018年10月，联邦法规放宽了对STLD计划的限制，将允许的期限从3个月延长至36个月。在2018年之前和之后，各州对STLD计划的销售或条款进行了扩展、限制或取消。州级政策与晚期癌症诊断之间的关联在很大程度上尚无记录。
研究2018年联邦法规前后，州级关于STLD计划的政策与晚期癌症诊断之间的关联。
设计、设置和参与者：这项横断面研究纳入了来自国家癌症数据库的47个州和哥伦比亚特区18至64岁新诊断为癌症的成年人（2016年1月至2020年2月）。患者按州级STLD计划政策分组：（1）2018年前后持续禁止STLD计划的州；（2）2018年后停止提供STLD计划的州；（3）允许销售对2018年联邦法规有额外限制的STLD计划的州；（4）无额外STLD监管的州。进行了差异分析，以评估2组、3组和4组与1组相比，2018年前（2016年1月至2018年6月）和2018年后（2019年1月至2020年2月）晚期诊断（III/IV期）的变化，包括所有癌症以及5种常见癌症，并对社会人口学因素（年龄组、性别、大都市状态、邮政编码级贫困程度）、诊断年份和州随机效应进行了调整。所有分析于2023年5月至2025年1月进行。
州级STLD计划政策。
晚期癌症诊断百分比的变化。
在1289366名新诊断为癌症的成年人中（平均[标准差]年龄为53[9.2]岁；536514[41.6%]为女性；73061[5.7%]为西班牙裔，110564[8.6%]为非西班牙裔亚洲人和太平洋岛民及其他，172246[13.4%]为非西班牙裔黑人；921722[71.5%]为非西班牙裔白人），604882人（46.9%）来自4组州（无额外STLD监管）。与1组（持续禁止STLD计划）相比，4组晚期诊断的净增加为0.76（95%置信区间，0.22 - 1.29）个百分点（P = 0.01），3组（有一些STLD监管）晚期诊断的净增加为0.84（95%置信区间，0.26 - 1.42）个百分点（P = 0.005）。女性乳腺癌和结直肠癌也观察到类似模式。
在这项关于州级STLD计划政策与晚期癌症诊断的横断面研究中，2018年联邦对STLD计划限制的放宽与没有或监管保护不足的州晚期癌症诊断的净增加相关，强调了州政策在监管STLD计划中的关键作用。
