Association of Medicaid expansion under the Affordable Care Act and overall survival among children with cancer.

Abstract

6507 Background: State Medicaid expansions under the Affordable Care Act are associated with increased Medicaid coverage among children, including those with cancer. Since the expansions did not directly affect Medicaid eligibility criteria for children, these changes suggest “welcome mat” effects, where previously uninsured children become enrolled in Medicaid after their parents gain coverage. Insurance improvements from the expansions have been associated with improved cancer outcomes for non-elderly adults. However, it is unclear whether the expansions also impacted childhood cancer outcomes. Methods: Data for children ages 0-14 years diagnosed with cancer from 2011-2017 were queried from central cancer registries covering cancer diagnoses from 43 states as part of the Centers for Disease Control’s National Program of Cancer Registries. The primary outcome was 2-year overall survival. We utilized difference-in-differences analyses to compare changes in 2-year survival from 2011-2013 to 2014-2017 between children who resided in states expanding Medicaid by 2014 vs. states not expanding Medicaid within the study period. Analyses were adjusted for covariates including age, race/ethnicity, sex, metropolitan residence, cancer type, and stage at diagnosis. Results: A total of 42,970 children with cancer were included. Overall, there were increases in 2-year survival among children in expansion states (90.5% in 2011-2013 to 91.4% in 2014-2017) but no change among children in non-expansion states (90.0% in 2011-2013 to 90.0% in 2014-2017). In adjusted difference-in-differences analyses, there was no significant change in survival after Medicaid expansion for children in expansion vs. non-expansion states (1.01 percentage points, 95% CI = -0.23 to 2.25, p = 0.11). In difference-in-differences analyses by race/ethnicity, there was a significant expansion-associated improvement in survival in Black children (3.97 percentage points, 95% CI = 0.02 to 7.93, p = 0.049) but not in White children (0.4 percentage points, 95% CI = -1.07 to 2.04, p = 0.54). There were also expansion-associated improvements in survival among children residing in counties with the lowest quartile of county income (5.88 percentage points, 95% CI = 0.38 to 11.38, p = 0.036) but not for those in higher income counties (1.15, 1.23, and 0.12 percentage points for 2nd, 3rd, and 4th quartiles, respectively). Conclusions: Medicaid expansion, through presumed increases in Medicaid coverage via welcome mat effects, was associated with increased 2-year survival for Black children and children residing in low-income counties. However, the concentration of Black children in states that have not expanded Medicaid highlights the need for further advocacy to more fully achieve improved outcomes. Future data are needed to clarify potential long-term impacts of Medicaid expansion on childhood cancer outcomes.