Medicaid Expansion and Racial Disparity in Timely Multidisciplinary Treatment in Muscle Invasive Bladder Cancer.

Abstract

Multidisciplinary cancer care (neoadjuvant chemotherapy+radical cystectomy (NAC+RC) or trimodality treatment (TMT)) is crucial for outcome of muscle invasive bladder cancer (MIBC), a potentially curable illness. Medicaid expansion through Affordable Care Act (ACA) increased insurance coverage especially among patients of racial minorities. This study aims to investigate the association between Medicaid expansion and racial disparity in timely treatment in MIBC. This quasi-experimental study analyzed 18-64-year-old Black and White people with stage II&III bladder cancer treated with NAC+RC or TMT from National Cancer Database 2008-2018. Primary outcome was timely treatment started within 45 days following cancer diagnosis. Racial disparity is the percentage-point difference between Black and White patients. Patients in expansion and nonexpansion states were compared using difference-in-differences (DID) and difference-in-difference-in-differences (DDD) analyses, controlling for age, sex, area level income, clinical stage, comorbidity, metropolitan status, treatment type, and year of diagnosis. The study included 4991 patients (92.3% White, N = 4605; 7.7% Black, N = 386). Percent of Black patients received timely care increased following the ACA in Medicaid expansion states (54.5% pre-ACA vs 57.4% post-ACA) whereas decreased in non-expansion states (69.9% pre-ACA vs 53.7% post-ACA). After adjusting covariates, Medicaid expansion was associated with a net 13.7 percentage-point reduction of Black-White disparity in timely receipt of MIBC treatment (95%CI: 0.5%-26.8%; p < .01). Medicaid expansion was associated with statically significant reduction in racial disparity between Black and White patients in timely multidisciplinary treatment for MIBC.