{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,11]],"date-time":"2026-10-11T17:51:48Z","timestamp":1791741108391,"version":"4.3.4"},"reference-count":51,"publisher":"Oxford University Press (OUP)","issue":"5","license":[{"start":{"date-parts":[[2024,4,25]],"date-time":"2024-04-25T00:00:00Z","timestamp":1714003200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2024,5,3]]},"abstract":"<jats:title>Abstract<\/jats:title>\n               <jats:p>The Patient Protection and Affordable Care Act (ACA) significantly reduced uninsured individuals and improved financial protection; however, escalating costs of cancer treatment has led to substantial out-of-pocket expenses, causing severe financial and mental health distress for individuals with cancer. Mixed evidence on the ACA's ongoing impact highlights the necessity of assessing health-spending changes across income groups for informed policy interventions. In our nationally representative survey evaluating the early- and long-term effects of the ACA on nonelderly adult patients with cancer, we categorized individuals-based income subgroups defined by the ACA for eligibility. We found that ACA implementation increased insurance coverage, which was particularly evident after 2 years of implementation. Early post-ACA (within two years of implementation), there were declines in out-of-pocket spending for the lowest and low-income groups by 26.52% and 38.31%, respectively, persisting long-term only for the lowest-income group. High-income groups experienced continuously increased out-of-pocket and premium spending by 25.39% and 34.28%, respectively, with a notable 122% increase in the risk of high-burden spending. This study provides robust evidence of income-based disparities in financial burden for cancer care, emphasizing the need for health care policies promoting equitable care and addressing spending disparities across income brackets.<\/jats:p>","DOI":"10.1093\/haschl\/qxae050","type":"journal-article","created":{"date-parts":[[2024,4,25]],"date-time":"2024-04-25T10:36:57Z","timestamp":1714041417000},"source":"Crossref","is-referenced-by-count":3,"title":["The Affordable Care Act and income-based disparities in health care coverage and spending among nonelderly adults with cancer"],"prefix":"10.1093","volume":"2","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5775-5637","authenticated-orcid":false,"given":"Olajumoke A","family":"Olateju","sequence":"first","affiliation":[{"name":"Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy , Houston, TX 77204-5000 , United States"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5680-3134","authenticated-orcid":false,"given":"Chan","family":"Shen","sequence":"additional","affiliation":[{"name":"Departments of Surgery and Public Health Sciences, Penn State Cancer Institute , Hershey, PA 17033 , United States"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6017-7500","authenticated-orcid":false,"given":"James Douglas","family":"Thornton","sequence":"additional","affiliation":[{"name":"Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy , Houston, TX 77204-5000 , United States"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2024,4,25]]},"reference":[{"issue":"1","key":"2024052916453806800_qxae050-B1","doi-asserted-by":"crossref","first-page":"17","DOI":"10.3322\/caac.21763","article-title":"Cancer statistics, 2023","volume":"73","author":"Siegel","year":"2023","journal-title":"CA Cancer J Clin"},{"key":"2024052916453806800_qxae050-B2","author":"National Cancer Institute"},{"issue":"1","key":"2024052916453806800_qxae050-B3","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1016\/j.jacr.2022.12.004","article-title":"Financial toxicity: a barrier to achieving health equity in cancer care","volume":"20","author":"Tucker-Seeley","year":"2023","journal-title":"J Am Coll Radiol."},{"issue":"12","key":"2024052916453806800_qxae050-B4","doi-asserted-by":"crossref","first-page":"e1035","DOI":"10.1200\/JOP.19.00138","article-title":"Coverage, financial burden, and the patient protection and affordable care act for patients with cancer","volume":"15","author":"Segel","year":"2019","journal-title":"J Oncol Pract"},{"issue":"3","key":"2024052916453806800_qxae050-B5","doi-asserted-by":"crossref","first-page":"476","DOI":"10.1002\/cncr.30369","article-title":"Measuring financial toxicity as a clinically relevant patient-reported outcome: the validation of the COmprehensive Score for financial Toxicity (COST)","volume":"123","author":"de Souza","year":"2017","journal-title":"Cancer"},{"issue":"1","key":"2024052916453806800_qxae050-B6","doi-asserted-by":"crossref","first-page":"85","DOI":"10.1002\/jso.25374","article-title":"Financial toxicity in cancer care: prevalence, causes, consequences, and reduction strategies","volume":"120","author":"Lentz","year":"2019","journal-title":"J Surg Oncol"},{"issue":"7","key":"2024052916453806800_qxae050-B7","doi-asserted-by":"crossref","first-page":"e2223149","DOI":"10.1001\/jamanetworkopen.2022.23149","article-title":"Financial hardship in cancer care\u2014the need to define and intervene on actionable metrics","volume":"5","author":"Dee","year":"2022","journal-title":"JAMA Netw Open"},{"issue":"10","key":"2024052916453806800_qxae050-B8","doi-asserted-by":"crossref","first-page":"1184","DOI":"10.6004\/jnccn.2019.7305","article-title":"Financial burdens of cancer treatment: a systematic review of risk factors and outcomes","volume":"17","author":"Smith","year":"2019","journal-title":"J Natl Compr Canc Netw."},{"key":"2024052916453806800_qxae050-B9"},{"issue":"5","key":"2024052916453806800_qxae050-B10","doi-asserted-by":"crossref","first-page":"525","DOI":"10.1001\/jama.2016.9797","article-title":"United States health care reform: progress to date and next steps","volume":"316","author":"Obama","year":"2016","journal-title":"JAMA"},{"key":"2024052916453806800_qxae050-B11","doi-asserted-by":"crossref","first-page":"m40","DOI":"10.1136\/bmj.m40","article-title":"Out-of-pocket spending and financial burden among low income adults after Medicaid expansions in the United States: quasi-experimental difference-in-difference study","volume":"368","author":"Gotanda","year":"2020","journal-title":"BMJ"},{"issue":"3","key":"2024052916453806800_qxae050-B12","doi-asserted-by":"crossref","first-page":"175","DOI":"10.1097\/PPO.0000000000000262","article-title":"Out-of-pocket spending under the Affordable Care Act for patients with cancer","volume":"23","author":"Dixon","year":"2017","journal-title":"Cancer J"},{"issue":"9","key":"2024052916453806800_qxae050-B13","doi-asserted-by":"crossref","first-page":"e2124280","DOI":"10.1001\/jamanetworkopen.2021.24280","article-title":"Associations of insurance churn and catastrophic health expenditures with implementation of the Affordable Care Act among nonelderly patients with cancer in the United States","volume":"4","author":"Albright","year":"2021","journal-title":"JAMA Netw Open"},{"issue":"2","key":"2024052916453806800_qxae050-B14","doi-asserted-by":"crossref","first-page":"e1921690","DOI":"10.1001\/jamanetworkopen.2019.21690","article-title":"The Affordable Care Act and insurance status, stage, and timely treatment among patients with cancer: what are the possible effects?","volume":"3","author":"Fu","year":"2020","journal-title":"JAMA Netw Open"},{"issue":"10","key":"2024052916453806800_qxae050-B15","doi-asserted-by":"crossref","first-page":"1187","DOI":"10.1016\/j.amjmed.2018.05.020","article-title":"Death or debt? National estimates of financial toxicity in persons with newly-diagnosed cancer","volume":"131","author":"Gilligan","year":"2018","journal-title":"Am J Med"},{"issue":"10","key":"2024052916453806800_qxae050-B16","doi-asserted-by":"crossref","first-page":"e1603","DOI":"10.1200\/OP.21.00095","article-title":"Affordable Care Act and cancer survivors\u2019 financial barriers to care: analysis of the National Health Interview Survey, 2009\u20132018","volume":"17","author":"Su","year":"2021","journal-title":"JCO Oncol Pract"},{"issue":"4","key":"2024052916453806800_qxae050-B17","doi-asserted-by":"crossref","first-page":"523","DOI":"10.1007\/s11764-019-00772-y","article-title":"Financial burden of cancer care under the Affordable Care Act: analysis of MEPS\u2014experiences with cancer survivorship 2011 and 2016","volume":"13","author":"Hong","year":"2019","journal-title":"J Cancer Surviv"},{"issue":"12","key":"2024052916453806800_qxae050-B18","doi-asserted-by":"crossref","first-page":"2892","DOI":"10.1002\/cncr.32836","article-title":"Impact of the Patient Protection and Affordable Care Act on cost-related medication underuse in nonelderly adult cancer survivors","volume":"126","author":"Barnes","year":"2020","journal-title":"Cancer"},{"issue":"3","key":"2024052916453806800_qxae050-B19","doi-asserted-by":"crossref","first-page":"347","DOI":"10.1001\/jamainternmed.2017.8060","article-title":"Out-of-pocket spending and premium contributions after implementation of the Affordable Care Act","volume":"178","author":"Goldman","year":"2018","journal-title":"JAMA Intern Med"},{"key":"2024052916453806800_qxae050-B20","author":"Agency for Healthcare Research and Quality"},{"issue":"7 Suppl 1","key":"2024052916453806800_qxae050-B21","doi-asserted-by":"crossref","first-page":"S44","DOI":"10.1097\/MLR.0b013e3181a23e3a","article-title":"The Medical Expenditure Panel Survey","volume":"47","author":"Cohen","year":"2009","journal-title":"Med Care"},{"key":"2024052916453806800_qxae050-B22","author":"Agency for Healthcare Research and Quality"},{"key":"2024052916453806800_qxae050-B23"},{"issue":"30","key":"2024052916453806800_qxae050-B24","doi-asserted-by":"crossref","first-page":"3749","DOI":"10.1200\/JCO.2013.49.1241","article-title":"Economic burden of cancer survivorship among adults in the United States","volume":"31","author":"Guy","year":"2013","journal-title":"J Clin Oncol."},{"key":"2024052916453806800_qxae050-B25","volume-title":"Health Insurance Coverage and the Affordable Care Act, 2010\u20132016","author":"Uberoi","year":"2016"},{"key":"2024052916453806800_qxae050-B26"},{"issue":"2","key":"2024052916453806800_qxae050-B27","doi-asserted-by":"crossref","first-page":"e200157","DOI":"10.1001\/jamanetworkopen.2020.0157","article-title":"Association of the US Affordable Care Act with out-of-pocket spending and catastrophic health expenditures among adult patients with traumatic injury","volume":"3","author":"Liu","year":"2020","journal-title":"JAMA Netw Open"},{"key":"2024052916453806800_qxae050-B28","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1200\/EDBK_100028","article-title":"An arm and a leg: the rising cost of cancer drugs and impact on access","volume":"41","author":"Leighl","year":"2021","journal-title":"Am Soc Clin Oncol Educ Book"},{"issue":"7","key":"2024052916453806800_qxae050-B29","doi-asserted-by":"crossref","first-page":"698","DOI":"10.1097\/MLR.0000000000000735","article-title":"Identifying increased risk of readmission and in-hospital mortality using hospital administrative data: the AHRQ Elixhauser comorbidity index","volume":"55","author":"Moore","year":"2017","journal-title":"Med Care"},{"issue":"1","key":"2024052916453806800_qxae050-B30","doi-asserted-by":"crossref","first-page":"88","DOI":"10.1111\/1468-0009.12042","article-title":"Trends in health care financial burdens, 2001 to 2009","volume":"92","author":"Blumberg","year":"2014","journal-title":"Milbank Q"},{"issue":"22","key":"2024052916453806800_qxae050-B31","doi-asserted-by":"crossref","first-page":"2712","DOI":"10.1001\/jama.296.22.2712","article-title":"Changes in financial burdens for health care: national estimates for the population younger than 65 years, 1996 to 2003","volume":"296","author":"Banthin","year":"2006","journal-title":"JAMA"},{"issue":"4","key":"2024052916453806800_qxae050-B32","doi-asserted-by":"crossref","first-page":"w298","DOI":"10.1377\/hlthaff.27.4.w298","article-title":"How many are underinsured? Trends among U.S. adults, 2003 and 2007","volume":"27","author":"Schoen","year":"2008","journal-title":"Health Aff (Millwood)"},{"key":"2024052916453806800_qxae050-B33","first-page":"1","article-title":"Too high a price: out-of-pocket health care costs in the United States. Findings from the Commonwealth Fund Health Care Affordability Tracking Survey. September-October 2014","volume":"29","author":"Collins","year":"2014","journal-title":"Issue Brief (Commonw Fund)"},{"key":"2024052916453806800_qxae050-B34"},{"key":"2024052916453806800_qxae050-B35","author":"Agency for Healthcare Research and Quality."},{"issue":"12","key":"2024052916453806800_qxae050-B36","doi-asserted-by":"crossref","first-page":"2645","DOI":"10.1002\/cncr.31288","article-title":"Patient Protection and Affordable Care Act Medicaid expansion and gains in health insurance coverage and access among cancer survivors","volume":"124","author":"Nikpay","year":"2018","journal-title":"Cancer"},{"issue":"5","key":"2024052916453806800_qxae050-B37","doi-asserted-by":"crossref","first-page":"1320","DOI":"10.1016\/j.ijrobp.2017.09.022","article-title":"Healthcare disparities in cancer patients receiving radiation: changes in insurance status after Medicaid expansion under the Affordable Care Act","volume":"99","author":"Chino","year":"2017","journal-title":"Int J Radiat Oncol Biol Phys"},{"issue":"11","key":"2024052916453806800_qxae050-B38","doi-asserted-by":"crossref","first-page":"1052","DOI":"10.1001\/jamaoto.2018.1792","article-title":"Association of the Patient Protection and Affordable Care Act with insurance coverage for head and neck cancer in the SEER database","volume":"144","author":"Cannon","year":"2018","journal-title":"JAMA Otolaryngol Head Neck Surg"},{"issue":"2","key":"2024052916453806800_qxae050-B39","doi-asserted-by":"crossref","first-page":"e92","DOI":"10.1200\/JOP.2017.027102","article-title":"Trends in insurance status among patients diagnosed with cancer before and after implementation of the Affordable Care Act","volume":"14","author":"Moss","year":"2018","journal-title":"J Oncol Pract"},{"key":"2024052916453806800_qxae050-B40","author":"Simpson"},{"key":"2024052916453806800_qxae050-B41"},{"issue":"2","key":"2024052916453806800_qxae050-B42","doi-asserted-by":"crossref","first-page":"216","DOI":"10.2105\/AJPH.2017.304166","article-title":"Effect of Medicaid expansions of 2014 on overall and early-stage cancer diagnoses","volume":"108","author":"Soni","year":"2018","journal-title":"Am J Public Health"},{"key":"2024052916453806800_qxae050-B43"},{"key":"2024052916453806800_qxae050-B44"},{"key":"2024052916453806800_qxae050-B45"},{"key":"2024052916453806800_qxae050-B46","doi-asserted-by":"crossref","first-page":"59","DOI":"10.2147\/SAR.S150253","article-title":"Relationship between buprenorphine adherence and relapse, health care utilization and costs in privately and publicly insured patients with opioid use disorder","volume":"9","author":"Ronquest","year":"2018","journal-title":"Subst Abuse Rehabil"},{"issue":"10","key":"2024052916453806800_qxae050-B47","doi-asserted-by":"crossref","first-page":"e2127784","DOI":"10.1001\/jamanetworkopen.2021.27784","article-title":"Medical service use and charges for cancer care in 2018 for privately insured patients younger than 65 years in the US","volume":"4","author":"Zaorsky","year":"2021","journal-title":"JAMA Netw Open"},{"issue":"2","key":"2024052916453806800_qxae050-B48","doi-asserted-by":"crossref","first-page":"103","DOI":"10.2217\/imt-2020-0152","article-title":"Immune checkpoint inhibitor use, multimorbidity and healthcare expenditures among older adults with late-stage melanoma","volume":"13","author":"Rai","year":"2020","journal-title":"Immunotherapy"},{"issue":"8","key":"2024052916453806800_qxae050-B49","doi-asserted-by":"crossref","first-page":"884","DOI":"10.1200\/JCO.21.01636","article-title":"Risk of adverse financial events in patients with cancer: evidence from a novel linkage between cancer registry and credit records","volume":"40","author":"Shankaran","year":"2022","journal-title":"J Clin Oncol."},{"issue":"24","key":"2024052916453806800_qxae050-B50","doi-asserted-by":"crossref","first-page":"2925","DOI":"10.1200\/JCO.2016.68.2518","article-title":"Updating the American Society of Clinical Oncology value framework: revisions and reflections in response to comments received","volume":"34","author":"Schnipper","year":"2016","journal-title":"J Clin Oncol."},{"issue":"11","key":"2024052916453806800_qxae050-B51","doi-asserted-by":"crossref","first-page":"580","DOI":"10.3390\/medicina56110580","article-title":"Universal healthcare in the United States of America: a healthy debate","volume":"56","author":"Zieff","year":"2020","journal-title":"Medicina (B Aires)"}],"container-title":["Health Affairs Scholar"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/healthaffairsscholar\/advance-article-pdf\/doi\/10.1093\/haschl\/qxae050\/57330494\/qxae050.pdf","content-type":"application\/pdf","content-version":"am","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/healthaffairsscholar\/article-pdf\/2\/5\/qxae050\/57985753\/qxae050.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/healthaffairsscholar\/article-pdf\/2\/5\/qxae050\/57985753\/qxae050.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,5,29]],"date-time":"2024-05-29T16:46:04Z","timestamp":1717001164000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/healthaffairsscholar\/article\/doi\/10.1093\/haschl\/qxae050\/7657982"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,4,25]]},"references-count":51,"journal-issue":{"issue":"5","published-print":{"date-parts":[[2024,5,3]]}},"URL":"https:\/\/doi.org\/10.1093\/haschl\/qxae050","relation":{},"ISSN":["2976-5390"],"issn-type":[{"value":"2976-5390","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2024,5]]},"published":{"date-parts":[[2024,4,25]]},"article-number":"qxae050"}}