Reduced Uninsured Rates and Racial Disparities in Insurance Coverage for Head and Neck Cancer Patients After Medicaid Expansion

Abstract

To evaluate the effect of Medicaid expansion on trends in insurance coverage for patients with head and neck cancer in the United States. Patients aged 18 to 64 with head and neck cancer diagnosed between 2008 and 2014 were identified in the SEER database. Insurance status (insured, Medicaid, or uninsured) at diagnosis was determined. Insurance coverage was compared between states that adopted Medicaid expansion in 2014 (“expansion states”) versus states without Medicaid expansion (“non-expansion states”). Categorical and continuous data were compared by chi-square test and Mann-Whitney U test, respectively. A total of 37,429 patients met inclusion criteria (72.9% in expansion states; 27.1% in non-expansion states). Between 2008 and 2014, 8% were uninsured. Non-expansion states had significantly higher uninsured rates than expansion states (12.9% vs 6.8%, P<.0001; OR 2.0, 95% CI 1.9-2.2). Racial and socioeconomic differences were notable, with non-expansion states having a higher percentage of black patients (21.8% vs 9% in expansion states, P<.00001) and subjects in these states living in regions with a higher percentage of poverty (17.3% vs 14.7% below poverty line, P<.00001). Uninsured rates were relatively stable between 2008 and 2013, followed by a 3% absolute reduction in 2014. A significant decrease in uninsured patients occurred in expansion states (7.2% in 2011-2013 vs. 2.5% in 2014, P<.0001), but not in non-expansion states (12.4% in 2011-2013 vs 12.3% in 2014, P=.99). Similarly, uninsured rates declined across all races and socioeconomic levels in expansion states, but no significant decrease occurred in non-expansion states. Prior to expansion (2011-2013), 7% of white patients, 10.6% of black patients, and 6.2% of other patients were uninsured in expansion states. Uninsured rates were more similar after Medicaid expansion: 2.3% of white patients, 2.2% of black patients, and 3.2% of other patients. Uninsured rates non-significantly rose among black patients living in non-expansion states (14.3% in 2011-2013 vs. 17% in 2014). Medicaid expansion in 2014 was associated with a significant reduction in uninsured status for patients with head and neck cancer, with the benefit limited to expansion states. Racial disparities in insurance coverage also decreased after Medicaid expansion in expansion states, but not in non-expansion states. Longer follow-up is essential to determine whether increased insurance coverage will translate into improved outcomes for head and neck cancer patients.