The Affordable Care Act and Insurance Status, Stage, and Timely Treatment Among Patients With Cancer: What Are the Possible Effects? | Breast Cancer | JAMA Network Open | JAMA Network
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Health Policy
February 19, 2020

The Affordable Care Act and Insurance Status, Stage, and Timely Treatment Among Patients With Cancer: What Are the Possible Effects?

Author Affiliations
  • 1Department of Surgery, Stanford University School of Medicine, Stanford, California
  • 2Stanford-Surgery Policy Improvement Research & Education Center, Stanford, California
  • 3Health Economics Resource Center, Department of Veterans Affairs, Palo Alto, California
  • 4Section of Trauma and Surgical Critical Care, Department of Surgery, Stanford University School of Medicine, Stanford, California
JAMA Netw Open. 2020;3(2):e1921690. doi:10.1001/jamanetworkopen.2019.21690

Cancer ranks among the top 3 most costly medical conditions to diagnose and treat in the United States. The economic burden of cancer care is projected to increase to $173 billion by 2020, an increase of 39% from 2010.1 It has been well documented that cancer represents a significant financial liability for patients and their families, particularly among the poorly insured.2 Since the passage of the Patient Protection and Affordable Care Act (ACA), the effect of Medicaid expansion on insurance coverage, access to care, and clinical outcomes of patients with cancer has not been well elucidated, despite intense scrutiny of the law’s effects.

Takvorian and colleagues3 used the National Cancer Database to examine the changes in health insurance and specific cancer health outcomes in nonelderly patients with breast, colon, and lung cancer after implementation of the ACA. In particular, the authors studied the time to treatment initiation (TTI) and stage of cancer at diagnosis. The authors categorized TTI by the percentage of patients treated within 30 days and within 90 days of diagnosis. Using a difference-in-differences analysis, the authors compared health insurance rates, cancer stage at diagnosis, and TTI from patients in Medicaid expansion and non–Medicaid expansion states. The study analyzed the period from 2011 to 2016, marking January 1, 2014, as the date of Medicaid expansion.

Both Medicaid expansion and nonexpansion states experienced declines in noninsurance rates, with more dramatic reductions among Medicaid expansion states. In addition, Medicaid expansion states experienced an increase in Medicaid coverage after ACA implementation during the study period. A sensitivity analysis was performed by eliminating the states that had elected to expand Medicaid coverage before 2014, the results of which demonstrated a greater uptake in coverage. These results corroborate and reinforce previous findings that insurance coverage rates have increased in Medicaid expansion compared with nonexpansion states.4

Regarding cancer health outcomes, patients in Medicaid expansion states were more likely to be diagnosed at an early stage than patients in nonexpansion states. The rate of diagnosis of advanced-stage cancers was higher in nonexpansion states at all periods of the study and remained unchanged after Medicaid expansion. The percentage of patients treated within 30 days decreased during the study period in both expansion states and nonexpansion states, as did the rate of treatment within 90 days, although to a lesser degree.

The ACA was passed 9 years ago with the intent of expanding health insurance coverage and improving access to care. The policy aimed to decrease health care expenditures by increasing coverage through a variety of channels, including optional state-by-state Medicaid expansion, the individual mandate, and the designation of tax credits toward purchasing health insurance. Thus far, research shows uninsured rates have declined since Medicaid expansion.4 It has also been shown that this expansion has decreased mortality rates, with clear evidence that Medicaid coverage has saved lives.5,6

Less clear, however, are the mechanisms by which the increased insurance coverage has been able to produce such reductions in mortality rates. One such mechanism, as this study suggests, may be improved access to care that increases timely cancer screening, diagnosis, and treatment. This study adds to previous studies on cancer-related health outcomes before and after Medicaid expansion, which were limited to 1 year after ACA implementation. The findings of improved early-stage cancer diagnosis in Medicaid expansion states is promising and may represent a channel for the observed improvements in mortality rates. However, the time to treatment results deserve context and further consideration. Time to treatment has been increasing in the United States since the mid-2000s, well before the implementation of the ACA,7 which was demonstrated again in this study. Furthermore, there was no difference in declining percentage of patients treated within 30 and 90 days between Medicaid expansion and nonexpansion states. This is somewhat puzzling, given the increased early-stage detection, and is especially worthy of further analysis because increased TTI is associated with increased mortality.7 It has been surmised that health insurance may contribute to increasing TTI by introducing additional administrative obligations such as prior authorization, leading to longer wait times. Newly insured and underinsured individuals may be particularly vulnerable to this. This issue necessitates additional study, because it has critical implications for health insurance policy and patient survival.

Cancer care is a multidisciplinary practice, requiring many high-cost specialists and expensive treatment options, including surgery, chemotherapy, and, increasingly, immunotherapy regimens. Furthermore, cancer treatment often takes months to years to fully complete. Cost containment and treatment affordability within cancer care is increasingly relevant because it can have a direct effect on a patient’s ability to initiate or complete treatment and therefore affects their health outcomes. In this analysis, Medicaid expansion was associated with a decrease in uninsured status and a small improvement in detecting early-stage cancer. This study highlights the necessity of further study surrounding the implications of health policy change on patients’ clinical trajectory and their out-of-pocket costs related to cancer treatment.

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Article Information

Published: February 19, 2020. doi:10.1001/jamanetworkopen.2019.21690

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Fu S et al. JAMA Network Open.

Corresponding Author: Lisa Knowlton, MD, MPH, Section of Trauma and Surgical Critical Care, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Dr, Room H3634, Stanford, CA 94305 (drlmk@stanford.edu).

Conflict of Interest Disclosures: None reported.

References
1.
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Langa  KM, Fendrick  AM, Chernew  ME, Kabeto  MU, Paisley  KL, Hayman  JA.  Out-of-pocket health-care expenditures among older Americans with cancer.  Value Health. 2004;7(2):186-194. doi:10.1111/j.1524-4733.2004.72334.xPubMedGoogle ScholarCrossref
3.
Takvorian  SU, Oganisian  A, Mamtani  R,  et al.  Association of Medicaid expansion under the Affordable Care Act with insurance status, cancer stage, and timely treatment among patients with breast, colon, and lung cancer.  JAMA Netw Open. 2020;3(2):e1921653. doi:10.1001/jamanetworkopen.2019.21653Google Scholar
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Carman  KG, Eibner  C, Paddock  SM.  Trends in health insurance enrollment, 2013-15.  Health Aff (Millwood). 2015;34(6):1044-1048. doi:10.1377/hlthaff.2015.0266PubMedGoogle ScholarCrossref
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Miller  S, Altekruse  S, Johnson  N, Wherry  L. Medicaid and mortality: new evidence from linked survey and administrative data. National Bureau of Economic Research working paper 26081. https://www.nber.org/papers/w26081. Issued July 2019. Accessed December 5, 2019.
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Goldin  J, Lurie  IZ, McCubbin  J. Health insurance and mortality: experimental evidence from taxpayer outreach. National Bureau of Economic Research working paper 26533. https://www.nber.org/papers/w26533. Issued December 2019. Accessed December 5, 2019.
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Khorana  AA, Tullio  K, Elson  P,  et al.  Time to initial cancer treatment in the United States and association with survival over time: an observational study.  PLoS One. 2019;14(3):e0213209. doi:10.1371/journal.pone.0213209PubMedGoogle Scholar
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