Impact of the Affordable Care Act and Medicaid Expansion on Insurance Coverage and Outcomes in Patients with HIV‐associated Aggressive B‐cell Non‐Hodgkin Lymphomas

Abstract

Introduction: HIV-associated lymphomas affect a uniquely disadvantaged group of patients, who were often denied insurance based on preexisting conditions until the Affordable Care Act (ACA) was signed in 2010. We investigated the impact of ACA and its Medicaid expansion in 2014 which covered the low-income strata, on outcomes among patients with HIV-associated aggressive B-cell non-Hodgkin lymphomas (HIV-aB-NHL). Methods: We used the National cancer database (NCDB) to identify HIV-associated aB-NHL patients aged 18–64 years from 2004 to 2017. We defined the pre-ACA period up to 2013 and the post-ACA period after 2014. States were grouped as Medicaid expansion adopted or not adopted. To reduce bias from advancements in anti-retroviral and chemo-immuno-therapies, we compared survival outcomes between 2010 to 2013 and 2014 to 2017. Kaplan-Meier method and a parametric Weibull model were used for survival analysis. Results: We identified 10,795 eligible patients with HIV-associated aB-NHL, comprised of 1802 Hispanics (16.7%), 3915 non-Hispanic blacks [NHB (36.3%)], 4727 Non-Hispanic Whites [NHW (43.8%)] and 351 other minorities (3.2%). The predominant diagnoses were diffuse large B-cell lymphoma (63.3%) and Burkitt lymphoma (20.1%). The figure shows the distribution of insurance status at diagnosis in Medicaid expansion (n = 4611) and non-expansion (n = 3091) states before and after the implementation of ACA stratified by race. Hispanics were more likely to be from residential zip codes in the lower educational quartile. A higher proportion of patients were seen at academic medical centers in expansion states across all races, and this further improved post-ACA. There was a significant improvement in survival seen among NHB (p < 0.01) post-ACA though the trend in Hispanics was not significant (P = 0.36). A multivariable survival analysis using the Weibull model adjusting for age, sex, insurance status, Charlson-Deyo comorbidity index, income, race, and Medicaid expansion status found statistically significant improvement in the states that adopted Medicaid expansion (HR 0.88, p < 0.01) though NHB race predicted poor survival (HR 1.49, p < 0.01). Keywords: Aggressive B-cell non-Hodgkin lymphoma, Cancer Health Disparities Conflicts of interests pertinent to the abstract. L. D. Anderson Consultant or advisory role: Celgene, BMS, Amgen, GSK, Janssen, Karyopharm, Beigene, AbbVie, Cellectar, and Sanofi Y. F. Madanat Consultant or advisory role: BluePrint Medicines, GERON, OncLive, Sierra Oncology, Stemline Therapeutics and Novartis G. Kaur Honoraria: BMS and Cellectar F. T. Awan Consultant or advisory role: Genentech, Astrazeneca, Abbvie, Janssen, Pharmacyclics, Gilead sciences, Kite pharma, Celgene, Karyopharm, MEI Pharma, Verastem, Incyte, Beigene, Johnson and Johnson, Dava Oncology, BMS, Merck, Cardinal Health, ADCT therapeutics, Epizyme, Caribou Biosciences, Cellecter Bisosciences Research funding: Pharmacyclics P. Ramakrishnan Geethakumari Consultant or advisory role: Kite Pharma, Bristol Myers Squibb, Rafael Pharma, Pharmacyclics LLC, ADC Therapeutics and Cellectar Biosciences