Medicaid Expansion States Research Articles

Impact of the Affordable Care Act on Insurance Status of Patients Newly Diagnosed With Kaposi Sarcoma

Background: The Affordable Care Act (ACA) role in changing the insurance composition of patients diagnosed with many dermatological conditions, such as Kaposi Sarcoma (KS), has not been assessed. Methods: The Surveillance, Epidemiology and End Results (SEER) Program, which captures cancer data from nearly 40% of cases in the US was used to extract cases. Cases were subgrouped by Medicaid expansion and non-expansion states. Standard mean differences were used as the statistical measure with P-value <0.05 used for statistical significance. Results: 2,465 patients met the inclusion criteria. In patients newly diagnosed with Kaposi sarcoma nationally before and after ACA implementation, the analysis showed there was no significant difference in the percentage of uninsured patients, Medicaid-insured patients, or privately insured patients. Pre- and post-ACA sub-analysis of patients newly diagnosed with Kaposi sarcoma in states that expanded Medicaid showed: (1) significant decrease in the percentage of uninsured patients (-5.81% difference, 95% CI -9.58% to -2.04%, P <.05); (2) significant increase in the percentage of Medicaid-insured patients (+9.36% difference, 95% CI +0.35% to +18.37%, P <.05) and (3) no significant difference in the percent of privately insured patients (-3.54% difference, 95% CI -13.74% to +6.64%). Sub-analysis in non-expansion states showed no difference between the insurance subtypes. Conclusion: Medicaid expansion played the largest role in reducing the percentage of uninsured patients newly diagnosed with KS. In states without Medicaid expansion, it is important that public health forces ensure adequate access to medications with services like the Ryan White HIV/AIDS Program

Racial disparities in cancer mortality in patients with gastrointestinal malignancies following Medicaid expansion.

6546 Background: Racial minorities experience disparities in receipt of cancer treatment and survival. The optional Medicaid expansion provision of the Affordable Care Act provided federal funding to participating states to improve healthcare access for disadvantaged populations by expanding Medicaid eligibility criteria. This study aimed to investigate the effect of Medicaid expansion on racial disparities in mortality among patients with gastrointestinal malignancies. Methods: A cross-sectional cohort study of patients with pancreatic ductal adenocarcinoma (PDAC), colorectal cancer (CRC), and gastric adenocarcinoma (GC) of any stage was conducted using the National Cancer Database (2009-2019). Difference-in-difference analysis (DID) was performed to compare adjusted 2-year mortality separately among Black and White patients residing in Medicaid expansion states (MES) and non-expansion states (non-MES) before (2009-2013) and after (2014-2019) expansion. Differences in receipt of surgery and chemotherapy were also evaluated. Results: A total of 86,052 patients were included for analysis, including 19,188 patients with PDAC, 60,404 with CRC, and 6,460 with GC. Two-year mortality decreased among Black patients with PDAC residing in MES compared to non-MES following expansion (DID -9.4%, p<0.001) (Table). Mortality also decreased among Black and White patients with CRC in MES compared to non-MES following expansion (DID -4.2%, p < 0.001 and -2.9%, p = 0.047). Among patients with GC, Black patients in MES experienced a marked reduction in mortality compared to non-MES (DID -7.7%, p = 0.07). Both Black and White stage 3-4 PDAC patients had an increase in receipt of chemotherapy in MES following expansion (DID 3.7%, p=0.28 and DID 2.7%, p=0.20). Rates of surgery, but not chemotherapy receipt, increased among Black patients with stage 4 CRC in MES following expansion (DID 5.7%, p=0.03 and 1.0%, p=0.66, respectively). A greater increase in receipt of chemotherapy was observed among Black patients with stage 4 GC in MES than in non-MES (DID 11%, p=0.06). Conclusions: Medicaid expansion was associated with a greater reduction in 2-year mortality rates for Black patients residing in MES than for those in non-MES. Existing racial disparities in mortality remained the same or worsened in non-MES but in almost all cases were mitigated in MES following Medicaid expansion. [Table: see text]

Racial disparities in utilization of first line targeted therapies for metastatic breast cancer.

6528 Background: This study evaluated whether there were racial disparities in utilization (decomposed as change in proportion of eligible patients initiating therapy over time and time to treatment initiation (TTI)) to CDK4/6 inhibitors and pertuzumab since FDA approval as first line (1L) treatment for ER+/HER2- and HER2+ metastatic breast cancer (MBC), respectively. Methods: This cohort study used the nationwide Flatiron Health electronic health record-derived de-identified database. Included women were ≥18 years old, diagnosed with de novo or recurrent MBC, who received 1L therapy, and documented as non-Hispanic White (NHW) or non-Hispanic Black/African American (NHB). Two cohorts were generated for patients with ER+/HER2- MBC diagnosed 3/2015-10/2021 and HER2+ MBC diagnosed 7/2012-9/2021. We estimated temporal trends in the proportion of NHW and NHB patients receiving respective therapy using logistic regression with natural cubic splines for time trends and tested for changes in uptake over time within each group as well as differences in trends between groups. A similar model was used for TTI among treatment initiators, using linear regression models. In addition to time and race, regression models included age, ECOG performance status, insurance, Medicaid expansion status, practice type, and proportion of black patients per practice among patients who met both cohort criteria. Results: 8318 patients (NHW=7006; NHB=1312) met ER+/HER2- cohort criteria and 2321 (NHW=1915; NHB=406) met HER2+ cohort criteria. There was a significant change over time in the proportion of NHW (p<0.0001) and NHB (p<0.0001) initiating 1L CDK4/6 inhibitors (Table). Temporal trends were also significantly different between NHW and NHB (p<0.0001). Higher ECOG performance status (OR=0.85 per unit increase, 95%CI 0.80-0.90; p<0.001) and an increasing proportion of black patients seen at practice (OR=0.45, 95%CI 0.29-0.71; p<0.001) were independent predictors of lower odds of initiating CDK4/6 inhibitors. Overall, 43% NHW vs 41% NHB received pertuzumab respectively. There was no significant difference in uptake trends for pertuzumab between NHW and NHB (p=0.41). There was no significant difference in the temporal trends of TTI for either CDK4/6 inhibitors (p=0.74) or pertuzumab (p=0.84). Conclusions: Utilization of CDK4/6 inhibitors steadily increased over time, however > 25% of eligible patients did not receive the drug, and less than half of individuals who met indication for pertuzumab were prescribed it. Racial disparities were significant for oral CDK4/6 inhibitors but not for intravenous pertuzumab. [Table: see text]

Access To Oncology Services In Rural Areas: Influence Of The 340B Drug Pricing Program.

Rural-urban cancer disparities, including greater mortality rates, are partially attributable to the limited availability of oncology services in rural communities. Without these services, rural residents may experience delays in timely treatment and may be less likely to complete recommended care. The 340B Drug Pricing Program allows eligible not-for-profit and public hospitals to purchase covered outpatient drugs, including high-cost oncology drugs, at discounted prices. Using 2011-20 data, we evaluated the relationship between new enrollment in the 340B program and oncology services initiation in rural general acute care hospitals that lacked oncology services in 2011. Compared with hospitals that remained unenrolled in the 340B program through 2020, hospitals that enrolled during 2012-18 were 8.3percentage points more likely to have added oncology services as of 2020. The newly participating hospitals that added oncology services were disproportionately located in Medicaid expansion states and in counties with lower uninsurance rates. These findings suggest that the 340B program facilitates expanded access to oncology services in some rural communities, but opportunities remain to address disparities in the most disadvantaged service areas.

Association of Medicaid expansion with timely receipt of treatment and survival among patients with HER2-enriched breast cancer.

6539 Background: HER2-enriched breast cancer (estrogen and progesterone receptors negative and HER2-positive) has no worse prognosis than other breast cancers if it is treated with HER2-targeted therapy. Medicaid expansion under the Affordable Care Act (ACA) has been shown to be associated with improved access to care and outcomes for many cancers, but its impact on care for HER2-enriched breast cancer is unknown. To fill this gap, we examined the association of Medicaid expansion with receipt of guideline-concordant treatment, time to treatment, and survival among newly diagnosed nonelderly women with HER2-enriched breast cancer. Methods: Women aged 18-62 years newly diagnosed with HER2-enriched breast cancer between 2010 and 2018 were identified from the National Cancer Database. Our primary outcomes included receipt of stage-based guideline-concordant treatment, initiation of treatment <60 days, and stage-specific 2-year overall survival. A difference-in-differences (DD) approach compared outcome changes following the expansion in Medicaid expansion vs. non-expansion states. A linear probability model estimated treatment outcome, and a flexible parametric survival model evaluated survival. All models were clustered at the state level and adjusted for age group, race/ethnicity, rurality of residence, zip code-level income, comorbidity, and diagnosis year. Results: A total of 31,354 patients with HER2-enriched breast cancer were included, including 19,255 in expansion states and 12,099 in non-expansion states. Compared to patients in expansion states, patients in non-expansion states were more likely to be racial/ethnic minorities, uninsured, and diagnosed at late-stage. Medicaid expansion was not significantly associated with changes in receipt of surgery for stage I-III disease but was associated with an increase of 4.42 percentage points (ppt, 95% CI: 0.09, 8.74) in receipt of chemotherapy/targeted therapy for stage IV disease, with an increase from 90.4% pre-expansion to 92.8% post-expansion in expansion states and a decrease from 93.7% to 91.9% in non-expansion states. Medicaid expansion was also significantly associated with a 2.41 ppt increase in initiating guideline-concordant treatment within 60 days (95% CI: 0.66, 4.17; 83.5% to 82.5% in expansion states vs. 86.6% to 83.7% in non-expansion states), and a 1.18 ppt increase in two-year survival rate (95% CI: 0.03, 2.33; 94.0% to 94.9% in expansion states vs. 94.3% to 94.1% in non-expansion states). The increase in two-year survival associated with Medicaid expansion was most prominent for stage III patients (DD=3.63 ppt; 95% CI: 0.64, 6.62). Conclusions: Medicaid expansion was associated with increased receipt of timely treatment and improved 2-year survival among nonelderly women newly diagnosed with HER2-enriched breast cancer.

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

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

Effects of Medicaid Expansion on Perceived Community Health Needs: Comparing and Contrasting the Content of CAH CHNAs Nationwide

The Patient Protection and Affordable Care Act (ACA) of 2010 included a requirement that every nonprofit hospital complete a Community Health Needs Assessment (CHNA) every three years. At the same time, the ACA offered significant financial incentives for states to broaden access to their Medicaid programs. Not all states took advantage of the Medicaid expansion incentives. Critical access hospitals (CAH) are deemed “critical” because they are the sole hospital in a geographic area. Such facilities are deeply enmeshed with the social determinants of health and other health-related challenges experienced by their communities. Their CHNA reports provide insight into the healthcare challenges community members cope with. The question explored in this study is: Do critical access hospital community health needs assessments in Medicaid expansion states report different community health care needs than those in non-expansion states? Both descriptive and analytic statistics indicate there are some differences between states, but there are also universal concerns in rural communities served by CAHs nationwide, regardless of Medicaid expansion status.

State mandatory paid medical leave policies and survival among adults with cancer in the US.

1511 Background: Cancer treatment is often costly and time intensive. Paid medical leave can help employed patients with cancer more effectively manage side effects and complete recommended cancer treatments without loss of income. Since 2012, several states have introduced mandatory paid medical leave policies. We examined whether mandatory paid medical leave policies were associated with better survival among working age adults with cancer. Methods: Adults ages 18 to 64 years diagnosed with cancer 2007- 2019 were identified from the Surveillance, Epidemiology, and End Results registry program covering 12 states. The primary outcome was overall survival (OS). The exposure of interest was the presence of state mandatory paid medical leave policies. Difference-in-differences (DID) analyses with additive hazards regression models compared changes in OS from pre- to post- mandatory paid sick leave policy implementation in states with vs. without paid sick leave policies. Models adjusted for year-quarter fixed effects, state fixed effects, state Medicaid expansion status, age, race, sex, marital status, metropolitan residence status, county-level income, cancer site, cancer stage, and insurance status. Clustered standard errors by state were achieved via the cluster bootstrap. The plausibility of the common trends assumption was tested using event study analyses and was satisfied for all analyses. Primary analyses focused on data from 2007-2016, where information on month of diagnosis, county, and insurance coverage status were available (note these variables are not available for 2017-2019), though sensitivity analyses with data through 2019 without these additional variables were conducted. Results: A total of 1,491,208 adults with cancer were identified. In adjusted DID analyses, after policy implementation, 1-year OS improved from 85.0% to 86.4% in states with mandatory medical leave policies compared to 85.1% to 85.6% in states without such policies. This translates to a 0.85% improvement in 1-year OS (hazard DID: -0.0007, 95% CI = -0.0016 to -0.0001, P = .027). The largest improvement was found among the uninsured population (hazard DID: -0.0038, 95% CI = -0.0076 to -0.0011, P = .013). In sensitivity analyses with abbreviated data through 2019, results were similar (DID for 1-year OS: 1.3%; hazard DID: -0.0010, 95% CI = -0.0025, 0.0001, P = .070). Conclusions: State mandatory paid medical leave was associated with improved survival for working-age adults with newly diagnosed cancer, particularly for those who are uninsured. Policy changes that better support patients through cancer treatment may pay off with improved cancer outcomes.

The Impact of Disparities on Minimally Invasive Esophagectomy After the 2014 Affordable Care Act Expansion: A Retrospective Analysis

The effect of Affordable Care Act Medicaid expansion on access to minimally invasive esophagectomy (MIE) is unknown. We hypothesize that greater Medicaid coverage resulting from ACA expansion would be associated with improved access to MIE, and performed an analysis of the National Cancer Database, comparing MIE rates in Medicaid expansion states to non-expansion states. MIE was more common in expansion states (30.37%vs 23.88%, P &lt; .001). A multivariable difference-in-differences analysis, however, suggested no effect in MIE rate due to Medicaid expansion. This finding suggests that access to care is more complex than access to insurance. Further study is required to characterize disparities in access to MIE.

Changes in cancer mortality after Medicaid expansion and the role of stage at diagnosis.

Medicaid expansion is associated with improved survival following cancer diagnosis. However, little research has assessed how changes in cancer stage may mediate improved cancer mortality or how expansion may have decreased population-level cancer mortality rates. Nationwide state-level cancer data from 2001 to 2019 for individuals ages 20-64 years were obtained from the combined Surveillance, Epidemiology, and End Results National Program of Cancer Registries (incidence) and the National Center for Health Statistics (mortality) databases. We estimated changes in distant stage cancer incidence and cancer mortality rates from pre- to post-2014 in expansion vs nonexpansion states using generalized estimating equations with robust standard errors. Mediation analyses were used to assess whether distant stage cancer incidence mediated changes in cancer mortality. There were 17 370 state-level observations. For all cancers combined, there were Medicaid expansion-associated decreases in distant stage cancer incidence (adjusted odds ratio = 0.967, 95% confidence interval = 0.943 to 0.992; P = .01) and cancer mortality (adjusted odds ratio = 0.965, 95% confidence interval = 0.936 to 0.995; P = .022). This translates to 2591 averted distant stage cancer diagnoses and 1616 averted cancer deaths in the Medicaid expansion states. Distant stage cancer incidence mediated 58.4% of expansion-associated changes in cancer mortality overall (P = .008). By cancer site subgroups, there were expansion-associated decreases in breast, cervix, and liver cancer mortality. Medicaid expansion was associated with decreased distant stage cancer incidence and cancer mortality. Approximately 60% of the expansion-associated changes in cancer mortality overall were mediated by distant stage diagnoses.

Impact of Medicaid expansion on inclusion of medications for opioid use disorder in homeless adults' treatment plans

IntroductionPeople experiencing homelessness (PEH) bear disproportionate opioid mortality. This article aims to determine how state Medicaid expansion under the Affordable Care Act impacted the inclusion of medications for opioid use disorder (MOUD) in treatment plans for housed versus homeless individuals. MethodsThe Treatment Episodes Data Set (TEDS) provided data on 6,878,044 U.S. treatment admissions between 2006 and 2019. Difference-in-differences analysis compared MOUD treatment plans and Medicaid enrollment for housed versus homeless clients in states that did and did not expand Medicaid. ResultsMedicaid expansion was associated with a 35.2 (95 % CI, 11.9 to 58.4) percentage point increase in Medicaid enrollment and an 8.51 (95 % CI, 1.13 to 15.9) percentage point increase in MOUD-inclusive treatment plans for housed and homeless clients alike. Yet the pre-existing MOUD disparity persisted, with PEH being 11.8 (95 % CI, −18.6 to −5.07) percentage points less likely to have MOUD-inclusive treatment plans. ConclusionsMedicaid expansion may be an effective tool for increasing MOUD treatment plans for PEH in the 11 states that have not yet implemented the policy, but additional efforts to increase MOUD initiation for PEH will be necessary for closing their treatment gap.

Medicaid expansion associated with no change in emergency department use across racial and ethnic groups.

To estimate changes in the emergency department (ED) visit rate, hospitalization share of ED visits, and ED visit volumes associated with Medicaid expansion among Hispanic, Black, and White adults. For the population of adults aged 26-64 with no insurance or Medicaid coverage, we obtained census population and ED visit counts during 2010-2018 in nine expansion and five nonexpansion states. The primary outcome was the annual number of ED visits per 100 adults ("ED rate"). The secondary outcomes were the share of ED visits leading to hospitalization, total number ("volumes") of all ED visits, ED visits leading to discharge ("treat-and-release") and ED visits leading to hospitalization ("transfer-to-inpatient"), and the share of the study population with Medicaid ("Medicaid share"). An event-study difference in differences design that contrasts pre- versus post-expansion changes in outcomes in Medicaid expansion and nonexpansion states. In 2013, the ED rate was 92.6, 34.4, and 59.2 ED visits among Black, Hispanic, and White adults, respectively. The expansion was associated with no change in ED rate in all three groups in each of the five post-expansion years. We found that expansion was associated with no change in the hospitalization share of ED visits and the volume of all ED visits, treat-and-release ED visits, and transfer-to-inpatient ED visits. The expansion was associated with an 11.7% annual increase (95% CI, 2.7%-21.2%) in the Medicaid share of Hispanic adults, but no significant change among Black adults (3.8%; 95% CI, -0.04% to 7.7%). ACA Medicaid expansion was associated with no changes in the rate of ED visits among Black, Hispanic, and White adults. Expanding Medicaid eligibility may not change ED use, including among Black and Hispanic subgroups.

The Impact of Medicaid Expansion on Early-Stage Hepatocellular Carcinoma Care.

The impact of Medicaid expansion (ME) on hepatocellular carcinoma (HCC) remains controversial, and heterogeneous effects on care processes may relate to sociodemographic factors. We sought to evaluate the association between ME and receipt of surgery in early-stage HCC. Patients diagnosed with early-stage HCC between 40 and 64 years of age were identified from the National Cancer Database and divided into pre- (2004-2012)and post- (2015-2017) expansion cohorts. Logistic regressionwas used to identify predictors of surgical treatment. Difference-in-difference (DID) analysis assessed changes in surgical treatment between patients living in ME and non-ME states. Among 19,745 patients, 12,220 (61.9%) were diagnosed before MEand 7525 (38.1%) after. Although overall utilization of surgery decreased after expansion (ME, pre-expansion: 62.2% versus post-expansion: 51.6%; non-ME, pre-expansion: 62.1% versus post-expansion: 50.8%, p < 0.001), this trend varied relative to insurance status. Notably, receipt of surgery increased among uninsured/Medicaid patients living in ME states after expansion (pre-expansion: 48.1%, post-expansion: 52.3%, p < 0.001). Moreover, treatment at academic or high-volume facilities increased the likelihood of undergoing surgery before expansion. After expansion, treatment at anacademic facility and living in anME state (OR 1.28, 95% CI 1.07-1.54, p < 0.01) were predictors of surgical treatment. DID analysis demonstrated increased utilization of surgery for uninsured/Medicaid patients living in ME states relative to non-ME states (uninsured/Medicaid: 6.4%, p < 0.05), although no differences were noted among patients withother insurance statuses (overall: 0.7%, private: -2.0%, other: 0.3%, all p > 0.05). Implementation of ME heterogeneously impacted utilization of care in early-stage HCC. Notably, uninsured/Medicaid patients residing in ME states demonstrated increased utilization of surgical treatment after expansion.

Postpartum Insurance Discontinuity and Use of Prescription Contraceptive Methods [ID: 1377734

INTRODUCTION: Medicaid eligibility income thresholds increase during pregnancy and historically ended 60 days postpartum. Thus, this postpartum period is especially vulnerable to insurance discontinuity, which may decrease access to contraception. METHODS: We used Pregnancy Risk Assessment Monitoring System survey data (2012–2020) in 42 states. Exposure, assessed 2 or more months after childbirth, was categorized as continuous insurance, insurance loss, discontinuous Medicaid-to-private, and discontinuous private-to-Medicaid. We used modified Poisson regression to estimate risk ratios (RRs) with 95% CIs for using contraception methods requiring prescriptions compared to nonprescription methods/none, adjusted for race and ethnicity, language, education, age, marital status, federal poverty level, and year. We then stratified by Medicaid expansion status at time of delivery. RESULTS: Of 246,088 respondents, 76.4% held continuous insurance from childbirth to 2 or more months postpartum, 11.9% lost insurance, 7.6% experienced discontinuity from Medicaid-to-private insurance, and 4.1% from private-to-Medicaid. Compared to continuous insurance, the adjusted RR for prescription postpartum contraception was 0.88 (CI 0.86–0.89) for loss of insurance, 0.99 (0.97–1.01) for discontinuous Medicaid-to-private, and 0.96 (0.93–0.98) for discontinuous private-to-Medicaid. Stratification by Medicaid expansion status yielded similar results. Of respondents in states or time periods without Medicaid expansion, 16.2% experienced insurance loss compared to 7.9% of those with Medicaid expansion. CONCLUSION: Insurance loss 2 or more months after childbirth was associated with decreased likelihood of prescription postpartum contraception, with a higher proportion of respondents without Medicaid expansion vulnerable to such insurance loss. Increased state adoption of the federal 12-month postpartum Medicaid extension option could improve access to prescription postpartum contraception.

Insurance Trends in Patients Diagnosed with Melanoma Before and After the Affordable Care Act: A National Database Study

Background: The Affordable Care Act (ACA) was intended, in part, to reduce the uninsured population. It underwent full implementation in 2014 with optional state Medicaid expansion and health insurance marketplaces. Prior to the ACA, studies show that insurance status affects cancer care, including prevention, diagnosis, stage at diagnosis, and management. ACA impact on malignant melanoma is unknown. In this study, the primary objective is to examine the impact of the ACA on insurance rates among patients diagnosed with malignant melanoma. Survival by insurance type was also assessed. Methods: A retrospective analysis of the Surveillance, Epidemiology and End Results (SEER) cancer registry was performed for malignant melanoma between 2007 (first year of insurance da-ta in SEER) and 2015. Standardized mean differences were used for 2007-2013 and 2014-2015 (after full ACA implementation) for the primary objective. Sub-analysis was performed for Med-icaid expansion and non-expansion states. The impact of insurance type (uninsured, Medicaid, non-Medicaid) on all-cause and cause-specific mortality was assessed via adjusted cox regression models. Results: Nationally, the ACA decreased percentage of uninsured patients (-1.12% to -2.26%, P&lt;0.05) and increased percentage of Medicaid enrollees (+1.53% to +4.02%, P&lt;.005) diagnosed with malignant melanoma. Expansion states showed decreased percentage of uninsured patients (-1.43% to -2.24%, P&lt;0.05) and increased percentage of Medicaid enrollees (+1.66% to +4.84%, P&lt;0.05). Non-expansion states showed no change in percentages of uninsured patients and Medicaid enrollees. All-cause and cause-specific mortality were decreased in uninsured and Medicaid patients diagnosed with malignant melanoma compared to non-Medicaid insured patients (reference group). Discussion: The ACA decreased the rate of patients diagnosed with malignant melanoma with uninsured status, but this was only significant in Medicaid expansion states. Although diagnosis of melanoma is associated with High Socioeconomic Status (SES), Medicaid expansion seems to have increased access to dermatologic care. Increasing the number of states expanding Medicaid may be beneficial. However, Medicaid patient have worse all-cause and cause-specific mortality compared to non-Medicaid insured patients. Addressing these disparities through policy is important to ensure insurance coverage translates to better outcomes.

Impact of Medicaid expansion on outcomes after abdominal aortic aneurysm repair

ObjectiveLack of insurance has been independently associated with an increased risk of in-hospital mortality after abdominal aortic aneurysm repair, possibly due to worse control of comorbidities and delays in diagnosis and treatment. Medicaid expansion has improved insurance rates and access to care, potentially benefiting these patients. We sought to assess the association between Medicaid expansion and outcomes after abdominal aortic aneurysm repair. MethodsA retrospective analysis of Healthcare Cost and Utilization Project State Inpatient Databases data from 14 states between 2012 and 2018 was conducted. The sample was restricted to first-record abdominal aortic aneurysm repairs in adults under age 65 in states that expanded Medicaid on January 1, 2014 (Medicaid expansion group) or had not expanded before December 31, 2018 (non-expansion group). The Medicaid expansion and non-expansion groups were compared between pre-expansion (2012-2013) and post-expansion (2014-2018) time periods to assess baseline demographic and operative differences. We used difference-in-differences multivariable logistic regression adjusted for patient factors, open vs endovascular repair, and standard errors clustered by state. Our primary outcome was in-hospital mortality. Outcomes were stratified by insurance type. ResultsWe examined 8995 patients undergoing abdominal aortic aneurysm repair, including 3789 (42.1%) in non-expansion states and 5206 (57.9%) in Medicaid expansion states. Rates of Medicaid insurance were unchanged in non-expansion states but increased in Medicaid expansion states post-expansion (non-expansion: 10.9% to 9.8%; P = .346; expansion: 9.7% to 19.7%; P < .001). One in 10 patients from both non-expansion and Medicaid expansion states presented with ruptured aneurysms, which did not change over time. Rates of open repair decreased in both non-expansion and Medicaid expansion states over time (non-expansion: 25.1% to 19.2%; P < .001; expansion: 25.2% to 18.4%; P < .001). On adjusted difference-in-differences analysis between expansion and non-expansion states pre-to post-expansion, Medicaid expansion was associated with a 1.02% absolute reduction in in-hospital mortality among all patients (95% confidence interval, −1.87% to −0.17%; P = .019). Additionally, among patients who were either on Medicaid or were uninsured (ie, the patients most likely to be impacted by Medicaid expansion), a larger 4.17% decrease in in-hospital mortality was observed (95% confidence interval, −6.47% to −1.87%; P < .001). In contrast, no significant difference-in-difference in mortality was observed for privately insured patients. ConclusionsMedicaid expansion was associated with decreased in-hospital mortality after abdominal aortic aneurysm repair among all patients and particularly among patients who were either on Medicaid or were uninsured. Our results provide support for improved access to care for patients undergoing abdominal aortic aneurysm repair through Medicaid expansion.

Impact of Medicaid Expansion on the Treatment and Outcomes of Intrahepatic Cholangiocarcinoma

IntroductionThe Affordable Care Act increased insurance coverage for patients residing in states that expanded Medicaid coverage, but its impact on the outcomes of intrahepatic cholangiocarcinoma (ICC) is not clear. Therefore, we examine the impact of Medicaid expansion (ME) on access to treatment and outcomes of ICC. MethodsWe queried the National Cancer Database (NCDB) data for patients with a diagnosis of ICC (2010–2018). Difference-in-difference (DID) analysis was performed to assess the impact of January 2014 ME on curative-intent surgical resection, multimodal therapy, neoadjuvant chemotherapy, 30-day mortality, and overall survival (OS). ResultsOf the 2150 patients included in the study,1574 (73.2%) and 576 (26.8%) patients lived in non-ME and ME states, respectively. On adjusted DID, ME was independently associated with receipt of curative-intent surgical resection (DID coefficient: 0.05, 95% confidence interval [95% CI]: 0.04–0.06, p = 0.002) and multimodal therapy (DID coefficient: 0.08, 95% CI: 0.06–0.10, p = 0.004). In addition, ME was associated with improved OS in ME states (hazard ratio [HR]: 0.73, 95% CI: 0.62–0.87, p = 0.001) but not in non-ME states (HR: 0.95, 95% CI: 0.80–1.12, p = 0.536). ConclusionME status consistently predicted increased utilization of care processes that improved ICC outcomes, including greater rates of curative-intent surgery and multimodal therapy.

The impact of Medicaid expansion on spending and utilization by older low-income Medicare beneficiaries.

To examine indirect spillover effects of Affordable Care Act (ACA) Medicaid expansions to working-age adults on health care coverage, spending, and utilization by older low-income Medicare beneficiaries. 2010-2018 Health and Retirement Study survey data linked to annual Medicare beneficiary summary files. We estimated individual-level difference-in-differences models of total spending for inpatient, institutional outpatient, physician/professional provider services; inpatient stays, outpatient visits, physician visits; and Medicaid and Part A and B Medicare coverage. We compared changes in outcomes before and after Medicaid expansion in expansion versus nonexpansion states. The sample included low-income respondents aged 69 and older with linked Medicare data, enrolled in full-year traditional Medicare, and residing in the community. ACA Medicaid expansion was associated with a 9.8 percentage point increase in Medicaid coverage (95% CI: 0.020-0.176), a 4.4 percentage point increase in having any institutional outpatient spending (95% CI: 0.005-0.083), and a positive but statistically insignificant 2.4 percentage point change in Part B enrollment (95% CI: -0.003 to 0.050, p = 0.079). ACA Medicaid expansion was associated with more institutional outpatient spending among older low-income Medicare beneficiaries. Increased care costs should be weighed against potential benefits from increased realized access to care.

Young Children's Mental Health Improves Following Medicaid Expansion to Low-Income Adults.

We investigate whether the Affordable Care Act's Medicaid expansion, implemented in 2014, improved the mental health of young children whose parents are in the policy's target population. We study children ages 2 to 3 in families with incomes less than 138% of the federal poverty level. We use restricted National Health Interview Survey data covering the United States from 2010 to 2018 to conduct an event study-a flexible version of difference-in-differences-of the Medicaid expansion's effects on Mental Health Indicator values for young children. We estimate effects using ordered logit regression. Children's mental health was statistically significantly better in Medicaid expansion states, compared with non-expansion states, in 3 of 4 post-expansion years. There were no differences between expansion and non-expansion states in the pre-expansion period, lending support to the causal interpretation that the expansion improved children's mental health. While Medicaid expansion targets low-income adults, our evidence indicates it improves low-income children's mental health. The expansion is a two-generation investment in prevention. It helps lay a foundation for strong mental health in children's early years and beyond.

MP75-07 ACCESS TO UROLOGIC CANCER CARE FOR MEDICAID-INSURED PATIENTS

You have accessJournal of UrologyCME1 Apr 2023MP75-07 ACCESS TO UROLOGIC CANCER CARE FOR MEDICAID-INSURED PATIENTS Folawiyo Laditi, James Nie, Walter Hsiang, Waez Umar, Afash Haleem, Victoria Marks, Mathew Buck, and Michael Leapman Folawiyo LaditiFolawiyo Laditi More articles by this author , James NieJames Nie More articles by this author , Walter HsiangWalter Hsiang More articles by this author , Waez UmarWaez Umar More articles by this author , Afash HaleemAfash Haleem More articles by this author , Victoria MarksVictoria Marks More articles by this author , Mathew BuckMathew Buck More articles by this author , and Michael LeapmanMichael Leapman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003349.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: While the Affordable Care Act has led to increased insurance rates amongst patients seeking urologic oncology care, most estimates on the improvement in oncologic outcomes have been conducted through hospital-based registries. These registries may not account for biases and variations in Medicaid acceptance amongst facilities. Empirical, patient-based estimates are needed to better understand barriers in access for Medicaid-practices for urologic malignancies. METHODS: Using a secret shopper approach, we contacted a representative sample of 389 Commission-on-Cancer accredited hospitals across the United States. Trained volunteers posed as a family member seeking urologic cancer care for their father with a simulated newly diagnosed renal mass. Facility-level characteristics were accessed from several publicly available databases. The primary outcome was to estimate Medicaid acceptance for urologic cancer care nationally. The secondary outcomes were to determine facility characteristics linked that increased or decreased the likelihood of Medicaid acceptance. RESULTS: 14.4% of Commission-on-Cancer urologic facilities did not accept new Medicaid patients. Importantly, acceptance was positively linked with state Medicaid expansion status (90.1% for expansion states vs non-expansion states 22.6% p<0.001), and higher state Medicaid-to-Medicare Fee indices (average of 0.700 for accepting facilities vs 0.649 for non-accepting facilities). Major teaching hospitals (93.8%) were more likely to accept Medicaid than non-major teaching hospitals (83.4%, p=0.018). Medical school affiliated hospitals were also more likely to accept Medicaid (89.2% acceptance for medical school affiliated hospitals vs 79.7% for non-medical school affiliated facilities, p=0.01). All other queried facility-level characteristics did not reach statistical significance. CONCLUSIONS: Using a secret shopper approach, we estimated Medicaid acceptance for urologic cancer care in a nationally representative sample of accredited cancer facilities from the patient perspective. We show that factors such as state Medicaid expansion status, Medicaid reimbursement, and teaching status were strongly associated with Medicaid Acceptance. Source of Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1081 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Folawiyo Laditi More articles by this author James Nie More articles by this author Walter Hsiang More articles by this author Waez Umar More articles by this author Afash Haleem More articles by this author Victoria Marks More articles by this author Mathew Buck More articles by this author Michael Leapman More articles by this author Expand All Advertisement PDF downloadLoading ...