Changes in Facility Share of Medicaid-Insured Patients with Urologic Cancers Following Implementation of the Patient Protection and Affordable Care Act

Abstract

ObjectivesTo examine Medicaid-insurance acceptance at facilities treating urologic cancers following implementation of the Affordable Care Act (ACA). MethodsWe conducted a retrospective, longitudinal study with a pre-post design. We accessed 2010-2017 data from the National Cancer Database, calculating the facility-level change in proportion of urologic cancer patients with Medicaid following implementation of the ACA. We used multivariable logistic regression to assess baseline clinical and demographic factors associated with changes in the proportion of patients at a facility insured through Medicaid. ResultsWe identified 630 facilities, including 287 in Medicaid expansion states and 343 in non-expansion states associated with 436,082 urologic cancer patients. The mean facility-level change in proportion of patients with Medicaid was +5.8% (95% CI 5.0-6.5%) in expansion states versus +0.6% (95% CI 0.2-0.9%) in non-expansion states. There were 179 facilities that experienced a decrease in the post-ACA period, representing 13.6% of facilities in expansion states and 40.8% in non-expansion states (p<0.001). Factors associated with a decrease in proportion of urologic cancer patients insured by Medicaid included non-expansion state status (OR 8.9, 95% CI 5.3-15.6, p<0.001), higher baseline proportion of patients with Medicaid (highest quartile versus lowest: OR 4.6, 95% CI 2.3-9.4, p<0.001) and high income zip code (highest versus lowest quartile: OR 3.1, 95% CI 1.5-6.6, p<0.001). ConclusionsUrologic cancer care for Medicaid-insured Americans remains unevenly distributed across cancer care centers, even in states that expanded coverage. Our findings suggest that this variation may reflect the effort of some facilities to reduce their financial exposure to increased numbers of Medicaid patients in the wake of ACA-supported state expansions.