Abstract
Health insurance coverage is associated with improved outcomes in patients with cancer. However, it is unknown whether Medicaid expansion through the Patient Protection and Affordable Care Act (ACA) was associated with improvements in the diagnosis and treatment of patients with genitourinary cancer. To assess the association of Medicaid expansion with health insurance status, stage at diagnosis, and receipt of treatment among nonelderly patients with newly diagnosed kidney, bladder, or prostate cancer. This case-control study included adults aged 18 to 64 years with a new primary diagnosis of kidney, bladder, or prostate cancer, selected from the National Cancer Database from January 1, 2011, to December 31, 2016. Patients in states that expanded Medicaid were the case group, and patients in nonexpansion states were the control group. Data were analyzed from January 2020 to March 2021. State Medicaid expansion status. Insurance status, stage at diagnosis, and receipt of cancer and stage-specific treatments. Cases and controls were compared with difference-in-difference analyses. Among a total of 340 552 patients with newly diagnosed genitourinary cancers, 94 033 (27.6%) had kidney cancer, 25 770 (7.6%) had bladder cancer, and 220 749 (64.8%) had prostate cancer. Medicaid expansion was associated with a net decrease in uninsured rate of 1.1 (95% CI, -1.4 to -0.8) percentage points across all incomes and a net decrease in the low-income population of 4.4 (95% CI, -5.7 to -3.0) percentage points compared with nonexpansion states. Expansion was also associated with a significant shift toward early-stage diagnosis in kidney cancer across all income levels (difference-in-difference, 1.4 [95% CI, 0.1 to 2.6] percentage points) and among individuals with low income (difference-in-difference, 4.6 [95% CI, 0.3 to 9.0] percentage points) and in prostate cancer among individuals with low income (difference-in-difference, 3.0 [95% CI, 0.3 to 5.7] percentage points). Additionally, there was a net increase associated with expansion compared with nonexpansion in receipt of active surveillance for low-risk prostate cancer of 4.1 (95% CI, 2.9 to 5.3) percentage points across incomes and 4.5 (95% CI, 0 to 9.0) percentage points among patients in low-income areas. These findings suggest that Medicaid expansion was associated with decreases in uninsured status, increases in the proportion of kidney and prostate cancer diagnosed in an early stage, and higher rates of active surveillance in the appropriate, low-risk prostate cancer population. Associations were concentrated in population residing in low-income areas and reinforce the importance of improving access to care to all patients with cancer.
Highlights
One of the major components of the 2010 Patient Protection and Affordable Care Act (ACA) was the expansion of Medicaid coverage eligibility to 138% of the federal poverty level (FPL)
Medicaid expansion was associated with a net decrease in uninsured rate of 1.1 percentage points across all incomes and a net decrease in the low-income population of 4.4 percentage points compared with nonexpansion states
Expansion was associated with a significant shift toward early-stage diagnosis in kidney cancer across all income levels and among individuals with low income and in prostate cancer among individuals with low income
Summary
One of the major components of the 2010 Patient Protection and Affordable Care Act (ACA) was the expansion of Medicaid coverage eligibility to 138% of the federal poverty level (FPL). While this expansion was intended to decrease rates of the individuals who are uninsured across the entire US population, in 2012, the Supreme Court made this expansion optional for states.[1] In January 2014, 25 states and the District of Columbia opted to expand Medicaid, and several more states expanded in the ensuing years.[2] This staggered and incomplete expansion pattern provides a natural experiment to study the association of the Medicaid expansion with population health. Being uninsured is associated with higher odds of presenting with advanced stage cancer,[10,11,12,13,14,15,16] being undertreated,[12,13,14,15] and having worse survival.[10,12,14,15,17,18] positive associations between health insurance coverage and outcomes are larger in magnitude for low-income populations.[19]
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