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Original Investigation
December 2018

Comparison of Insurance Status and Diagnosis Stage Among Patients With Newly Diagnosed Cancer Before vs After Implementation of the Patient Protection and Affordable Care Act

Author Affiliations
  • 1Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
  • 2Intramural Research Department, American Cancer Society, Atlanta, Georgia
  • 3Office of the Chief Medical Officer, American Cancer Society, Atlanta, Georgia
JAMA Oncol. 2018;4(12):1713-1720. doi:10.1001/jamaoncol.2018.3467
Key Points

Question  After implementation of the Patient Protection and Affordable Care Act, how did insurance status and stage at diagnosis change by state and sociodemographic factors among patients with newly diagnosed cancer?

Findings  In this population-based registry study of 2.5 million nonelderly patients with cancer diagnosed from 2010 to 2014 from 40 states, the percentage of uninsured patients decreased in almost all states; the largest decreases were in Medicaid expansion states with high baseline uninsured rates. Sociodemographic disparities in uninsured rate were diminished or nearly eliminated in expansion states but remained high in nonexpansion states.

Meaning  Medicaid expansion may mitigate disparities among sociodemographic subpopulations.

Abstract

Importance  Having health insurance is a strong determinant of cancer outcomes in the United States, and Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) may have reduced the prevalence of uninsured patients. Prior research has only assessed the aggregate effects of expansions, and little is known about changes in uninsured patients by state and key sociodemographic groups, including sex, race/ethnicity, census tract–level poverty, and rurality.

Objective  To examine changes in the percentage of uninsured patients and stage at diagnosis among nonelderly patients with cancer by state and key sociodemographic groups after implementation of the ACA.

Design, Setting, and Participants  This study used difference-in-differences analysis to determine the percentage of uninsured patients and early-stage cancer diagnoses among patients aged 18 to 64 years from the population-based cancer registries of 40 states before (January 1, 2010, to December 31, 2013) and after (January 1, 2014, to December 31, 2014) the ACA Medicaid expansion. Data analysis was performed from November 2017 to April 2018.

Main Outcomes and Measures  Changes in the percentage of uninsured patients and early-stage diagnoses.

Results  A total of 2 471 154 patients (mean age, 52.7 years; age range, 18-64 years; 51.4% female; 70.9% non-Hispanic white) were included from Medicaid expansion (n = 1 234 156) and nonexpansion (n = 1 236 998) states. In 2014, the percentage of uninsured patients decreased in almost all states. However, decreases were greater in expansion than nonexpansion states and were greatest in expansion states with high baseline uninsured rates. For example, the percentage of uninsured patients decreased from 8.3% before implementation of the ACA to 2.1% (−6.2 difference) after implementation of the ACA in the expansion state of Kentucky compared with 9.1% to 7.5% (−1.5 difference) in the nonexpansion state of Tennessee. In expansion states, the decreases in the percentage of uninsured patients were higher among minorities and patients in high-poverty or rural areas, diminishing or eliminating disparities. In contrast, sociodemographic disparities in the percentage of uninsured patients remained high in nonexpansion states. Stage at diagnosis shifted slightly to earlier stage for most cancer types in Medicaid expansion states.

Conclusions and Relevance  This study found state variation in reductions in the percentage of uninsured patients among nonelderly patients with cancer after implementation of the ACA, with larger decreases in expansion than nonexpansion states. Disparities in the percentage of uninsured patients by race/ethnicity, census tract–level poverty, and rurality were diminished or eliminated in Medicaid expansion states but remained high in nonexpansion states, highlighting the promising role of Medicaid expansion in reducing disparities among sociodemographic subpopulations. Future studies should monitor changes in cancer presentation, treatment, and outcomes after implementation of the ACA.

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