Background: Lung cancer is the leading cause of cancer-related death in the US. In 2017 there were approximately 222,500 newly diagnosed lung cancer cases with 80-85% being NSCLC. Thirty percent of them was diagnosed before 65 years old. Among elderly lung cancer patients, studies demonstrated that uninsured and Medicaid patients were less likely to receive guideline-concordant therapy and have higher overall mortality. It remains unknown how insurance status influences the treatment and survival of NSCLC patients less than 65 years. Methods: NSCLC patients were identified through Surveillance, Epidemiology, and End Results (SEER) 18 Program from 2007-2014. Baseline patient features including age, gender, race, education, income, insurance, tumor grade, stage and treatment were included. Subjects aged 65 years or older or those who developed secondary cancers were excluded. Logistic regression and Cox proportional hazards modeling were employed using SAS 9.4 to determine the affect of insurance on treatment and survival. Results: A total of 56,743 NSCLC patients were included. Medicaid and uninsured patients were significantly less likely to be treated than privately insured patients across all stages. Medicaid or uninsured status was associated with higher overall and cause-specific mortality compared to insured after controlling for confounding factors regardless of stage and age. However, there was a 14.7% mortality reduction seen among uninsured patient who were diagnosed after 2010 compared to before 2010 (p < 0.05). Conclusions: Medicaid insured NSCLC patients have poorer survival outcome compared to the uninsured and insured, regardless of stage. Despite the passage of the ACA and Medicaid expansion in 2010, the overall mortality among NSCLC patients with Medicaid remained unchanged. However, the uninsured did witness a mortality benefit which could be possibly due to selection bias – among uninsured patients, those with more comorbidities were more likely to be enrolled in expanded Medicaid than relatively younger, healthier uninsured patients and thus left the latter a better survival. The long-term benefit of ACA on NSCLC outcomes warrants further investigation.