Affordable care act and 4-year all-cause mortality among U.S. working-age adults with or without cancer: 2000-2015

It is unclear how associations of socioeconomic and behavioral factors with mortality in U.S. working-age adults with cancer changed after implementing the Affordable Care Act (ACA). Therefore, we examined changes in associations of prognostic factors with 4-year mortality risk in working-age American adults after implementing the ACA by cancer status.

We conducted 4 retrospective cohort studies, using the National Health Interview Survey data from 2000 to 2015, linked to the National Death Index through December 2019. The primary outcome was 4-year all-cause mortality. Multivariable logistic regression was used to quantify the associations of various factors with 4-year mortality in each cohort for all, cancer and non-cancer participants. Difference-in-difference analyses were performed to compare adjusted odds ratios (aOR) before and after the ACA implementation.

The 4 retrospective cohort studies included ~307 million U.S. working-age adults (aged 18-64 years, with 74-78 million weighted participants in each cohort) who participated in the survey years 2000, 2005, 2010, and 2015. Cancer prevalence among U.S. working-age adults rose 13.0% (5,150 per 100,000 in the 2015 cohort versus 3,970 per 100,000 in the 2000 cohort). Difference-in-difference analyses showed aORs of cancer, sex, age, race, and smoking-status for 4-year all-cause mortality risk remained unchanged throughout the 15 years. However, post-ACA regional gaps widened among cancer patients, with increasing aORs in the South and West versus the Northeast region. Post-ACA age-gaps reduced among non-cancer participants, with decreasing aORs in participants aged 55-64 or 45-54 years (versus 18-34 years).

Cancer prevalence among U.S. working-age adults rose significantly during 2000-2015. There were no significant post-ACA changes in associations of key prognostic factors with 4-year mortality in all participants. However, the influences of ACA implementation on socioeconomic disparities differed by cancer status. Further works should focus on its influence by other disease status, including diabetes and cardiovascular disease.