Employer Mandates and Chronic Disease: Assessing the Impact of the San Francisco Employer Mandate on Cancer Outcomes

Ten years after San Francisco passed an employer mandate, we assess the effect of the law in increasing rates of health insurance and insurance generosity, and the health effects for chronic disease. Specifically, we focus on the immediate and long-term effects on cancer, a condition where early detection and treatment can significantly improve survival and thus access to health insurance is an important determinant of outcomes.

We conduct difference-in-difference analyses, comparing San Francisco with three controls groups, the surrounding counties, similar counties in Great California, and another large metropolis, Los Angeles. We use the California Health Interview Survey to establish the increase in insurance rates in San Francisco relative to the control groups. We also test for greater insurance generosity and higher rates of continuous coverage as a result of the mandate. We then use the Surveillance, Epidemiology, and End Results (SEER) Program Database to determine the impact of the employer mandate in improving health effects as a result of the insurance expansion.

We find that as a result of the employer mandate, the likelihood of late stage diagnosis for cancer patients was approximately 1% lower in San Francisco, a small, but statistically significant result. Survival outcomes saw much larger changes. The greatest effects occurred for lymphoma and leukemia; implementation of the employer mandate resulted in a 4% increase in one year survival rates and a 2% increase in two-year survival rates. Comparing the pre and post mandate period, San Francisco saw a 7% relative increase in survival rates. The results were similar, but smaller in magnitude for the two most common types of cancer, lung and breast. For lung cancer, the employer mandate resulted in a 3% increase and 1% increase in one and year survival rates, respectively. These numbers were 0.5% and 1% respectively for breast cancer. Breast cancer survival rates are likely attenuated by initially high survival rates; mortality rates are less than 5%, the lowest of all cancers, so there is little room to improve.

This study is the first to investigate the effect of newly gained health insurance from an employer mandate on health outcomes. Employer mandates are an important policy mechanism, because they have the largest impact on individuals right above the poverty line, who are not eligible for Medicaid, but often do not have health insurance through their employer or have inadequate insurance. We show that the SF employer mandate resulted in higher rates of insurance coverage which results in the earlier detection of cancer and significantly increased rates of survival, especially among vulnerable populations. This is a positive signal for the long-term health effects in addressing the health burden of chronic conditions of the Affordable Care Act’s employer mandate as that follows the same structure as this mandate.