Health care and politics are inextricably linked in the USA. Just as elections are influenced by patterns in social behaviours and the economy, health-care access and affordability are influenced by elections1 and ideological disagreements regarding the involvement of governments in health care.2 Historically, Democrats have focused on increased access to health insurance coverage and Republicans have advocated for smaller government and privatisation of health care. The Affordable Care Act was enacted in 2010 and by 2014, the number of individuals without health insurance had decreased substantially. Attempts to repeal and replace the Affordable Care Act began in 2011, and in 2017, changes to the Affordable Care Act were made, including reversal of the insurance mandate, a shortened enrolment period for the Marketplace health insurance plan, reduced funding for enrolment outreach, and elimination of cost-sharing subsidies to insurers. These changes coincided with increases in the number of individuals without health insurance and inability to access health care due to costs.3
The Affordable Care Act has had a profound effect on access to health care for patients with cancer, especially those with a low income. Enhanced coverage and access has translated to the diagnosis of cancer at earlier stages of disease and more timely treatment; survivors have benefited from improved affordability and enhanced access to care for chronic disease.4
We obtained 2011–19 data from the annual Behavioral Risk Factor Surveillance System nationwide survey to investigate temporal correlations between the evolving political climate, specific policies, and insurance coverage for cancer survivors. According to the Behavioral Risk Factor Surveillance System, the number of cancer survivors without health insurance steadily declined after the 2010 passage of the Affordable Care Act and implementation of provisions for coverage led to the highest number of people with health insurance (weighted average 619 190 [7·9%] of cancer survivors). Beginning in 2017, progressive destabilisation of the private insurance markets has led to a reversal of insurance gains and a slow increase in the number of people without health insurance consistent with the erosion of Affordable Care Act policies (weighted average 809 631 [9·9%] of cancer survivors in 2019), particularly in states that did not expand Medicaid eligibility (appendix). This has resulted in more than 190 000 cancer survivors losing their health insurance since the 2016 US elections.
Although causality cannot be concluded in an observational analysis, it is striking how these observed patterns coincide with policy changes. As physicians, researchers, and health-care advocates, the idea that someone with cancer would be uninsured contradicts good health policy. These patterns merit continued attention in the midst of a contentious election season, with another Supreme Court hearing on the constitutionality of the Affordable Care Act expected imminently.
Supplementary Material
Acknowledgments
HAM was supported by the National Institutes of Health (BIRCWH K12HD043446). XH received funding from AstraZenca, outside the submitted work. JC was funded in part through the NIH/NCI Cancer Center Support Grant (P30 CA008748). KRY and FC declare no competing interests. The findings and conclusions in this Correspondence represent those of the authors and do not necessarily represent the official position of the American Cancer Society.
Contributor Information
Haley A Moss, Division of Gynecologic Oncology, Duke University Medical Center, Durham, NC 27710, USA.
Xuesong Han, American Cancer Society, Atlanta, GA, USA.
K Robin Yabroff, American Cancer Society, Atlanta, GA, USA.
Junzo Chino, Division of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA.
Fumiko Chino, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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