The impact of the Patient Protection and Affordable Care Act on insurance coverage and cancer-directed treatment in HIV-infected patients with cancer in the United States

Impact of the Affordable Care Act and Medicaid Expansion Among Patients With HIV-Associated Aggressive B-Cell Non-Hodgkin Lymphomas

PURPOSE

To study the influence of the Affordable Care Act (ACA) policy and its Medicaid expansion on insurance status and survival in patients with HIV with aggressive lymphoma.

METHODS

We used the National Cancer Database, a hospital-based national registry, to identify adults age 18-64 years with HIV-associated aggressive B-cell non-Hodgkin lymphomas (HIV-a-B-NHLs), diagnosed during 2007 to 2016. Survival analysis was performed on a subset of patients with HIV-a-B-NHL for whom location data were available who resided in Medicaid expansion-adopted and nonadopted states. Using a quasi-experimental difference-in-difference model, the difference in adjusted 2-year survival rates obtained with a flexible parametric Weibull model was compared for states that adopted the Medicaid expansion of ACA against those that did not adopt the expansion.

RESULTS

We identified 8,231 patients with HIV-a-B-NHL and 50,650 non-HIV patients with a-B-NHL. We found that a lower proportion of individuals were uninsured at diagnosis in the expansion states compared with nonexpansion states. We also found that the ACA policy adoption led to a reduction in the proportion of uninsured individuals with HIV-a-B-NHL in expansion states of 34.9%, compared with 15.9% in non-expansion-adopted states. There was a statistically significant improvement in the 2-year survival rate among patients with HIV-a-B-NHL in the expansion compared with nonexpansion states with the adoption of ACA (7.17% v 1.58%, P = .02).

CONCLUSION

Using a novel quasi-experimental model, we found that the ACA policy corresponded with a greater survival improvement in patients with HIV-a-B-NHL within Medicaid expansion-adopted states compared with nonexpansion states. We believe that this evidence should be taken into consideration in future policy making.

The effect of medicaid expansion on access to healthcare, health behaviors and health outcomes between expansion and non-expansion states

In 1965, Medicaid was implemented with the goal of providing insurance to low-income individuals. In 2010, the Patient Protection Affordable Care Act (PPACA) standardized and expanded the eligibility criteria for the Medicaid program across the United States. In 2012, the constitutionality of this expansion was challenged and the Supreme Court rules that states were only required to expand their Medicaid program if they wanted to utilize the additional funds allotted by the federal government. This research paper examines the effects of the expansion by looking at health data in expansion and non-expansion states. Specifically, this study compares metrics designed to gauge healthcare access, health behaviors and health outcomes to determine if expansion has had positive overall effect on expansion states. We conclude that expansion states have demonstrated improved access to healthcare and improved health outcomes than the non-expansion states. Changes in health behaviors reflect mixed results - HIV screenings are higher in expansion states but participation in flu vaccinations show no statistical significance difference between the two groups. Given the results of this analysis, we conclude that Medicaid expansion is an effective policy for states to pursue in order to further the original objectives of Medicaid by improving the health of low-income recipients.

Real-world implications of nonbiological factors with staging, clinical management, and prognostic prediction in pancreatic ductal adenocarcinoma

BACKGROUND

The American Joint Committee on Cancer (AJCC) tumor-node-metastasis (TNM) staging system focuses on traditional biological factors (BFs). The present study incorporates nonbiological factors (NBFs) into the AJCC-TNM staging system in terms of the advanced clinical management and prognostic-prediction accuracy of pancreatic ductal adenocarcinoma (PDAC).

METHODS

Eight thousand three hundred and thirty eligible patients with PDAC were obtained from Surveillance, Epidemiology, and End Results database between January 1, 2011, and December 31, 2015. Multivariate Cox proportional hazards regression analysis and Kaplan-Meier curves were used to testify the feasibility of cancer-specific survival (CSS) prediction based on TNM-NBF stages.

RESULTS

The large population-based study demonstrated that NBFs (insurance status, marital status, county-level median household income, and unemployment) were significant prognostic indicators (p < 0.005), and multivariate Cox regression analysis demonstrated that the NBF1 stage carried a 29.4% increased risk of cancer-specific mortality than NBF0 stage (p < 0.001). The concordance index of TNM-NBF stage was 0.755 (95% confidence interval: 0.740-0.769).

CONCLUSIONS

The novel NBF stage was independently associated with CSS of PDAC. In addition, combining TNM with the NBF stage could provide better clinical management and prognostic-prediction accuracy.

Palliative Care Use Among People Living With HIV and Cancer: An Analysis of the National Cancer Database (2004-2018)

PURPOSE

People living with HIV (PLWH) diagnosed with cancer are less likely to receive quality cancer treatment compared with HIV-negative patients. Timely provision of palliative care (PC) during cancer treatment can increase patient's survival and improve quality of life. Our objective was to compare the use of PC by HIV status among adults diagnosed with cancer in the United States.

METHODS

More than 19 million individuals age 18-90 years diagnosed with the 11 most common cancers among PLWH were selected from the National Cancer Database (2004-2018). The National Cancer Database defined PC as any surgery, radiation, systemic therapy, or pain management treatment with noncurative intent. Multivariable logistic regression was used to examine associations between HIV status and PC receipt by cancer site and stage after adjustment for covariates.

RESULTS

The study population included 52,306 HIV-positive (average age: 56.5 years) and 19,115,520 HIV-negative (average age: 63.7 years) cancer cases. PLWH diagnosed with stage I-III cancer were more likely to receive PC compared with their HIV-negative counterparts (adjusted odds ratio [aO]: 1.96; 95% CI, 1.80 to 2.14); however, they were also less likely to receive curative cancer treatment (aOR, 0.48; 95% CI, 0.40 to 0.59). PLWH diagnosed with stage IV cancer were less likely to receive PC (aOR, 0.70; 95% CI, 0.66 to 0.74) compared with HIV-negative patients. When evaluated by cancer site, PLWH diagnosed with stage IV lung (aOR, 0.80; 95% CI, 0.73 to 0.87) and colorectal (aOR, 0.72, 95% CI, 0.54 to 0.95) cancers were less likely to receive PC than HIV-negative patients.

CONCLUSION

PLWH diagnosed with stage IV cancer, particularly lung and colorectal cancers, were less likely to receive PC compared with cancer patients without HIV. PLWH with nonmetastatic disease were more likely to receive PC but less likely to receive curative treatment, reinforcing that clinical strategies are needed to improve the quality of care among PLWH.

Early Medicaid Expansion and Cancer Mortality

BACKGROUND

Although Medicaid expansion is associated with decreased uninsured rates and earlier cancer diagnoses, no study has demonstrated an association between Medicaid expansion and cancer mortality. Our primary objective was to quantify the relationship between early Medicaid expansion and changes in cancer mortality rates.

METHODS

We obtained county-level data from the National Center for Health Statistics for adults aged 20-64 years who died from cancer from 2007 to 2009 (preexpansion) and 2012 to 2016 (postexpansion). We compared changes in cancer mortality rates in early Medicaid expansion states (CA, CT, DC, MN, NJ, and WA) vs nonexpansion states through a difference-in-differences analysis using hierarchical Bayesian regression. An exploratory analysis of cancer mortality changes associated with the larger-scale 2014 Medicaid expansions was also performed.

RESULTS

In adjusted difference-in-differences analyses, we observed a statistically significant decrease of 3.07 (95% credible interval = 2.19 to 3.95) cancer deaths per 100 000 in early expansion vs nonexpansion states, which translates to an estimated decrease of 5276 cancer deaths in the early expansion states during the study period. Expansion-associated decreases in cancer mortality were observed for pancreatic cancer. Exploratory analyses of the 2014 Medicaid expansions showed a decrease in pancreatic cancer mortality (-0.18 deaths per 100 000, 95% confidence interval = -0.32 to -0.05) in states that expanded Medicaid by 2014 compared with nonexpansion states.

CONCLUSIONS

Early Medicaid expansion was associated with reduced cancer mortality rates, especially for pancreatic cancer, a cancer with short median survival where changes in prognosis would be most visible with limited follow-up.

The Affordable Care Act's Medicaid Expansion and Impact Along the Cancer-Care Continuum: A Systematic Review

BACKGROUND

Health reform and the merits of Medicaid expansion remain at the top of the legislative agenda, with growing evidence suggesting an impact on cancer care and outcomes. A systematic review was undertaken to assess the association between Medicaid expansion and the goals of the Patient Protection and Affordable Care Act in the context of cancer care. The purpose of this article is to summarize the currently published literature and to determine the effects of Medicaid expansion on outcomes during points along the cancer care continuum.

METHODS

A systematic search for relevant studies was performed in the PubMed/MEDLINE, EMBASE, Scopus, and Cochrane databases. Three independent observers used an abstraction form to code outcomes and perform a quality and risk of bias assessment using predefined criteria.

RESULTS

A total of 48 studies were identified. The most common outcomes assessed were the impact of Medicaid expansion on insurance coverage (23.4% of studies), followed by evaluation of racial and/or socioeconomic disparities (17.4%) and access to screening (14.5%). Medicaid expansion was associated with increases in coverage for cancer patients and survivors as well as reduced racial- and income-related disparities.

CONCLUSIONS

Medicaid expansion has led to improved access to insurance coverage among cancer patients and survivors, particularly among low-income and minority populations. This review highlights important gaps in the existing oncology literature, including a lack of studies evaluating changes in treatment and access to end-of-life care following implementation of expansion.