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    Original Investigation
    April 22, 2020

    Association of Medicaid Insurance With Survival Among Patients With Small Cell Lung Cancer

    Author Affiliations
    • 1Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
    • 2Department of Radiation Oncology, University of Tennessee Health Science Center, Memphis
    • 3Division of Cancer Medicine Division, The University of Texas MD Anderson Cancer Center, Houston
    JAMA Netw Open. 2020;3(4):e203277. doi:10.1001/jamanetworkopen.2020.3277
    Key Points español 中文 (chinese)

    Question  Is Medicaid coverage associated with a survival benefit compared with being uninsured among US patients with small cell lung cancer (SCLC)?

    Findings  This cohort registry analysis of 181 784 patients with SCLC included in the US National Cancer Database found no association of Medicaid coverage with a survival advantage compared with no insurance. Patients with private insurance, managed care plans, and Medicare had better survival than did Medicaid recipients or uninsured patients even after adjusting for confounding factors.

    Meaning  Medicaid coverage was not associated with improved overall survival among patients with SCLC, thus highlighting an opportunity for health care policy intervention in this population.


    Importance  Small cell lung cancer (SCLC) is an aggressive neoplasm requiring rapid access to subspecialized multidisciplinary care. For this reason, insurance coverage such as Medicaid may be associated with oncologic outcomes in this disproportionately economically vulnerable population. With Medicaid expansion under the Affordable Care Act, it is important to understand outcomes associated with Medicaid coverage among patients with SCLC.

    Objective  To determine the association of Medicaid coverage with survival compared with other insurance statuses.

    Design, Setting, and Participants  This cohort study included adult patients with limited-stage (LS) and extensive-stage (ES) SCLC in the US National Cancer Database from 2004 to 2013. Data were analyzed in January 2019.

    Main Outcomes and Measures  Patients were analyzed with respect to insurance status. Associations of insurance status with survival were interrogated with univariate analyses, multivariable analyses, and propensity score matching.

    Results  A total of 181 784 patients with SCLC (93 131 [51.2%] female; median [interquartile range] age; 67 [60-75] years for patients with LS-SCLC and 68 [60-75] years for patients with ES-SCLC) were identified, of whom 70 247 (38.6%) had LS-SCLC and 109 479 (60.2%) had ES-SCLC. On univariate analyses of patients with LS-SCLC, Medicaid coverage was not associated with a survival advantage compared with being uninsured (hazard ratio, 1.02; 95% CI, 0.96-1.08; P = .49). Likewise, on multivariable analyses of patients with ES-SCLC, compared with being uninsured, Medicaid coverage was not associated with a survival advantage (hazard ratio, 1.00; 95% CI, 0.96-1.03; P = .78). After propensity score matching, median survival was similar between the uninsured and Medicaid groups both among patients with LS-SCLC (14.4 vs 14.1 months; hazard ratio, 1.05; 95% CI, 0.98-1.12; P = .17) and those with ES-SCLC (6.3 vs 6.4 months; hazard ratio, 1.00; 95% CI, 0.96-1.04; P = .92).

    Conclusions and Relevance  Despite of billions of dollars in annual federal and state spending, Medicaid was not associated with improved survival in patients with SCLC compared with being uninsured in the US National Cancer Database. These findings suggest that there are substantial outcome inequalities for SCLC relevant to the policy debate on the Medicaid expansion under the Affordable Care Act.