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Original Investigation
March 23, 2020

Association of Medicaid Expansion With Insurance Coverage Among Children With Cancer

Author Affiliations
  • 1Medical student, Saint Louis University School of Medicine, St Louis, Missouri
  • 2Brown School Master of Public Health Program, Washington University in St Louis, St Louis, Missouri
  • 3Center for Health Economics and Policy, Institute for Public Health, Washington University in St Louis, St Louis, Missouri
  • 4Program in Occupational Therapy, Washington University School of Medicine, St Louis, Missouri
  • 5Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
  • 6Department of Pediatrics Hematology/Oncology, St Louis Children’s Hospital, Washington University School of Medicine, St Louis, Missouri
  • 7Siteman Cancer Center, Washington University in St Louis, St Louis, Missouri
JAMA Pediatr. Published online March 23, 2020. doi:10.1001/jamapediatrics.2020.0052
Key Points

Question  Is early Medicaid expansion under the Affordable Care Act associated with changes in private insurance, Medicaid, and no insurance coverage among children with cancer?

Findings  This cross-sectional study of 21 069 children aged 1 to 14 years used difference-in-differences analyses to demonstrate significantly increased Medicaid uptake (5.25%) and decreased private insurance (−4.52%) in states with early Medicaid expansion relative to nonexpansion states, particularly in regions of high poverty. Small reductions in uninsured rates (−0.73%) in expansion relative to nonexpansion states were also observed.

Meaning  This analysis found that state Medicaid expansion was associated with increased Medicaid coverage in children with cancer overall and in some subgroups, primarily due to switching from private coverage, but also through reductions in the uninsured.

Abstract

Importance  Despite evidence of improved insurance coverage under the Affordable Care Act and Medicaid expansion among adults with cancer, little is known regarding the association of these policies with coverage among children with cancer.

Objective  To assess the association of early Medicaid expansion with rates of Medicaid coverage, private coverage, and no uninsurance among children with cancer.

Design, Setting, and Participants  This cross-sectional study used data from the Surveillance, Epidemiology, and End Results (SEER) database from January 1, 2007, to December 31, 2015, to identify children diagnosed with cancer at ages 0 to 14 years in the United States. Data were analyzed from July 27, 2017, to October 7, 2019.

Exposures  Changes in insurance status at diagnosis after early Medicaid expansion in California, Connecticut, Washington, and New Jersey (EXP states) were compared with changes in nonexpansion (NEXP) states (Arkansas, Georgia, Hawaii, Iowa, Kentucky, Louisiana, Michigan, New Mexico, and Utah).

Main Outcomes and Measures  Difference-in-differences (DID) analyses were used to compare absolute changes in insurance status (uninsured, Medicaid, private/other) at diagnosis before (2007 to 2009) and after (2011 to 2015) expansion in EXP relative to NEXP states.

Results  A total of 21 069 children (11 265 [53.5%] male; mean [SD] age, 6.18 [4.57] years) were included. A 5.25% increase (95% CI, 2.61%-7.89%; P < .001) in Medicaid coverage in children with cancer was observed in EXP vs NEXP states, with larger increases among children of counties with middle to high (adjusted DID estimates, 10.18%; 95% CI, 4.22%-16.14%; P = .005) and high (adjusted DID estimates, 6.13%; 95% CI, 1.10%-11.15%; P = .05) poverty levels (P = .04 for interaction). Expansion-associated reductions of children reported as uninsured (−0.73%; 95% CI, −1.49% to 0.03%; P = .06) and with private or other insurance (−4.52%; 95% CI, −7.16% to −1.88%; P < .001) were observed. For the latter, the decrease was greater for children from counties with middle to high poverty (−9.00%; 95% CI, −14.98% to −3.02%) and high poverty (−6.38%; 95% CI, −11.36% to −1.40%) (P = .04 for interaction).

Conclusions and Relevance  In this study, state Medicaid expansions were associated with increased Medicaid coverage in children with cancer overall and in some subgroups primarily owing to switching from private coverage, particularly in counties with higher levels of poverty but also through reductions in the uninsured.

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