OP-JNCI190247 1063..1066

The effect of the Dependent Coverage Expansion (DCE) under the Affordable Care Act (ACA) on receipt of colorectal cancer treatment has yet to be determined. We identified newly diagnosed DCE–eligible (aged 19–25 years, n1⁄41924) and DCE– ineligible (aged 27–34 years, n1⁄48313) colorectal cancer patients from the National Cancer Database from 2007 to 2013. All statistical tests were two-sided. Post-ACA, there was a statistically significant increase in early-stage diagnosis among DCE– eligible (15 percentage point increase, confidence interval 1⁄4 9.8, 20.2; P < .001), but not DCE–ineligible (P 1⁄4 .09), patients. DCE– eligible patients resected for IIB–IIIC colorectal cancer were more likely to receive timely adjuvant chemotherapy (hazard ratio 1⁄4 1.34, 95% confidence interval 1⁄4 1.05 to 1.71; 7.0 days’ decrease in restricted mean time from surgery to chemotherapy, P 1⁄4 .01), with no differences in DCE–ineligible patients (hazard ratio 1⁄4 1.10, 95% confidence interval 1⁄4 0.98 to 1.24; 2.1 days’ decrease, P 1⁄4 .41) post-ACA. Our findings highlight the role of the ACA in improving access to potentially lifesaving cancer care, including a shift to early-stage diagnosis and more timely receipt of adjuvant chemotherapy. Colorectal cancer is a leading cause of cancer death in the United States, and the incidence and mortality rates among young adults are rising (1,2). Health insurance coverage is a strong predictor of quality cancer care (3), and lack of coverage is associated with late-stage diagnosis and receipt of suboptimal care (3,4). Consensus guidelines disseminated by the National Comprehensive Cancer Network and the American Society of Clinical Oncology recommend the use of adjuvant chemotherapy for all stage IIB–IIIC colon cancer patients (5,6), and delayed time to treatment is associated with worse survival (7,8). Receiving quality colorectal cancer care might be especially problematic for young adults, who historically had the highest uninsured rate in the country (9). In September 2010, the Dependent Coverage Expansion (DCE) under the Affordable Care Act (ACA) went into effect, allowing young adults up to 26 years of age to be covered under their parents’ private health insurance. The ACA lead to an increase in health insurance coverage (10,11), use of preventive services (12), and earlier stage of diagnosis for some cancers (4,13) among DCE–eligible individuals. However, the effect of the ACA on access to timely cancer care, such as potentially lifesaving adjuvant chemotherapy, has not been evaluated. The objective of our study is to examine whether DCE was associated with improved care among young adults with colorectal cancer. We used data from the National Cancer Database, a nationwide hospital-based cancer registry, which includes approximately 70% of all newly diagnosed cancer patients in the United States (14). The “Adolescent and Young Adult Site Recode” scheme (15) was used to identify patients diagnosed with colorectal cancer from January 2007 to June 2010 (pre-ACA) and January 2011 to December 2013 (post-ACA). The second half of 2010 was excluded as a washout and phase-in period. Stage at diagnosis was coded according to the AJCC Cancer Staging Manual Sixth Edition (16). Difference-in-differences (DD) analyses were used to evaluate changes in percentage of patients covered with private insurance and diagnosed with early-stage cancer (0 and I) B R IE F C O M M U N IC A T IO N Received: October 16, 2019; Revised: December 2, 2019; Accepted: December 11, 2019 © The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com 1063 JNCI J Natl Cancer Inst (2019) 112(10): djz235 doi: 10.1093/jnci/djz235 First published online December 19, 2019