Abstract
The association of the Patient Protection and Affordable Care Act (ACA) with insurance status and cancer stage at diagnosis among patients with renal cell carcinoma (RCC) is unknown. To test the hypothesis that the ACA may be associated with increased access to care through expansion of insurance, which may vary based on income. This retrospective cohort analysis included patients diagnosed with RCC from January 1, 2010, to December 31, 2016, in the National Cancer Database. Data were analyzed from July 1 to December 31, 2020. The periods from 2010 to 2013 and from 2014 to 2016 were defined as pre- and post-ACA implementation, respectively. Patients were categorized as living in a Medicaid expansion state or not. Implementation of the ACA. The absolute percentage change (APC) of insurance coverage was calculated before and after ACA implementation in expansion and nonexpansion states. Secondary outcomes included change in stage at diagnosis, difference in the rate of insurance change, and change in localized disease between expansion and nonexpansion states. Adjusted difference-in-difference modeling was performed. The cohort included 78 099 patients (64.7% male and 35.3% female; mean [SD] age, 54.66 [6.46] years), of whom 21.2% had low, 46.2% had middle, and 32.6% had high incomes. After ACA implementation, expansion states had a lower proportion of uninsured patients (adjusted difference-in-difference, -1.14% [95% CI, -1.98% to -1.41%]; P = .005). This occurred to the greatest degree among low-income patients through the acquisition of Medicaid (APC, 11.0% [95% CI, 8.6%-13.3%]; P < .001). Implementation of the ACA was also associated with an increase in detection of stage I and II disease (APC, 4.0% [95% CI, 1.6%-6.3%]; P = .001) among low-income patients in expansion states. Among patients with RCC, ACA implementation was associated with an increase in insurance coverage status in both expansion and nonexpansion states for all income groups, but to a greater degree in expansion states. The proportion of patients with localized disease increased among low-income patients in both states. These data suggest that ACA implementation is associated with earlier RCC detection among lower-income patients.
Highlights
The Patient Protection and Affordable Care Act (ACA) is considered by many to be the most significant change in health care in the US since the passage of the Social Security Act Amendments of 1965 (Medicare and Medicaid Act).[1]
Among patients with renal cell carcinoma (RCC), ACA implementation was associated with an increase in insurance coverage status in both expansion and nonexpansion states for all income groups, but to a greater degree in expansion states
Insurance coverage increased secondary to Medicaid enrollment; this occurred to the greatest degree among low-income patients through the acquisition of Medicaid (APC, 11.0% [95% CI, 8.6%-13.3%]; P < .001)
Summary
The Patient Protection and Affordable Care Act (ACA) is considered by many to be the most significant change in health care in the US since the passage of the Social Security Act Amendments of 1965 (Medicare and Medicaid Act).[1] The ACA focuses on improving access to care by increasing health insurance coverage.[2] Provisions of the ACA increased the availability of health insurance through several mechanisms, including elimination of preexisting conditions for insurance coverage denial, an employer mandate to offer health insurance, establishment of a marketplace for individuals to purchase insurance, penalty for not having insurance, and expansion of Medicaid eligibility.[1] In this framework, states had an opportunity to opt out of Medicaid expansion. It was hypothesized that owing to overall health policy changes of the ACA, individuals would increase access to insurance and cancer care.[4,5]
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