Health Care Disparities in Cancer Patients Receiving Radiation: Changes in Insurance Status After Medicaid Expansion Under the Affordable Care Act

Abstract

Tocompare insurance status in cancer patients receiving radiation before and after Medicaid expansion under the Patient Protection and Affordable Care Act (ACA), in both expanded and non-expanded states. Newly diagnosed cancer patients aged 18 to 64years who received radiation from 2011 to 2014 were compiled from the Surveillance, Epidemiology, and End Results database. Patients with a prior cancer diagnosis or unknown insurance status were excluded. Insurance rates at diagnosis were examined before (2011-2013) and after Medicaid expansion (2014) and compared between states that fully or did not fully expand Medicaid. A total of 197,290 patients were analyzed. Of these, 73% lived in expanded states. After expansion, there was a 53% relative decrease in uninsured rates in expanded states (4.3%-2.1%) and a 5% relative decrease in non-expanded states (8.4%-8.0%) (P < .0001). In expanded states, the uninsured rate decreased regardless of race (whites: relative decrease 56%, 4.3% to 1.9%; blacks: relative decrease 50%, 6.0 to 3.0%; both P < .0001) or county poverty level (low poverty: relative decrease 46%, 3.9% to 2.1%; high poverty: relative decrease 60%, 4.5% to 1.8%; both P < .0001). In non-expanded states, a decrease in uninsured levels was seen primarily in whites (relative decrease 9%, 7.8% to 7.1%, P < .0001; blacks: relative increase 7%, 9.9% to 10.6%, P = .37) and those living in areas with the lowest poverty (relative decrease 27%, 4.8% to 3.5%, P = .04; high poverty: relative increase 2%, 10.9% to 11.1%, P = .17). Blacks and those living in the highest poverty areas had the greatest level of benefit from full expansion (absolute benefit 2.0%-2.3%, P = .0093 and P = .0029, respectively). Medicaid expansion in 2014 significantly decreased uninsured rates for cancer patients receiving radiation. Full expansion decreased rates of uninsurance to a greater degree and seemed to decrease racial and economic disparities.