Health Care Disparities in Cancer Patients Receiving Radiation: Changes in Insurance Status After Medicaid Expansion Under the Affordable Care Act

Explicit inference: A meta-replication of SEER cancer registry research evaluating the Affordable Care Act's Medicaid expansion

OBJECTIVES

Among the provisions within the Affordable Care Act (ACA), expanding Medicaid was arguably the greatest contributor to increasing access to care. For over a decade, researchers have investigated how Medicaid expansion impacted cancer outcomes. Over this same decade, statistical theory illuminated how state-based policy research could be compromised by invalid inference. After reviewing the literature to identify the inference strategies of state-based cancer registry Medicaid expansion research, this study aimed to assess how inference decisions could change the interpretation of Medicaid expansion's impact on staging, treatment, and mortality in cancer patients.

DATA SOURCES

Cancer case data (2000-2019) was obtained from the Surveillance, Epidemiology, End Results (SEER) programme. Cases included all cancer sites combined, top 10 cancer sites combined, and three screening amenable cancers (colorectal, female breast, female cervical).

STUDY DESIGN

A Difference-in-Differences design estimated the association between Medicaid expansion and four binary outcomes: distant stage, initiating treatment >1 month after diagnosis, no surgery recommendation, and death. Three inference techniques were compared: (1) traditional, (2) cluster, and (3) Wild Cluster Bootstrap.

DATA COLLECTION

Data was accessed via SEER*Stat.

PRINCIPAL FINDINGS

Estimating standard errors via traditional inference would suggest that Medicaid expansion was associated with delayed treatment initiation and surgery recommendations. Traditional and clustered inference also suggested that Medicaid expansion reduced mortality. Inference using Wild Cluster Bootstrap techniques never rejected the null hypotheses.

CONCLUSIONS

This study reiterates the importance of explicit inference. Future state-based, cancer policy research can be improved by incorporating emerging techniques. These findings warrant caution when interpreting prior SEER research reporting significant effects of Medicaid expansion on cancer outcomes, especially studies that did not explicitly define their inference strategy.

Financial Toxicity in Radiation Oncology: Impact for Our Patients and for Practicing Radiation Oncologists

With rising costs of diagnosis, treatment, and survivorship, financial burdens on patients with cancer and negative effects from high costs, called financial toxicity (FT), are growing. Research suggests that FT may be experienced by more than half of working-age cancer survivors and a similar proportion may incur debt or avoid recommended prescription medications due to treatment costs. As FT can lead to worse physical, psychological, financial, and survival outcomes, there is a discrete need to identify research gaps around this issue that constrain the development and implementation of effective screening and innovative care delivery interventions. Prior research, including within a radiation oncology-specific context, has sought to identify the scope of FT among patients with cancer, develop assessment tools to evaluate patient risk, quantify financial sacrifices, and qualify care compromises that occur when cancer care is unaffordable. FT is a multifactorial problem and potential solutions should be pursued at all levels of the health care system (patient-provider, institutional, and systemic) with specific regard for patients' individual/local contexts. Solutions may include selecting alternative treatment schedules, discussing financial concerns with patients, providing financial navigation services, low-cost transportation options, and system-wide health policy shifts. This review summarizes existing FT research, describes tools developed to measure FT, and suggests areas for intervention and study to help improve FT and outcomes for radiation oncology patients.

Management of metastatic melanoma in Texas: disparities in the utilization of immunotherapy following the regulatory approval of immune checkpoint inhibitors

BACKGROUND

The utilization of modern-immunotherapies, notably immune checkpoint inhibitors (ICIs), has increased markedly in patients with metastatic melanoma over the past decade and are recommended as standard treatment. Given their increasing adoption in routine care for melanoma, understanding patient access to immunotherapy and patterns of its use in Texas is crucial as it remains one of the few states without Medicaid expansion and with high rates of the uninsured population. The objectives of this study were to examine the trend in the utilization of immunotherapy and to determine factors associated with immunotherapy utilization among patients with metastatic melanoma in the era of ICIs in Texas.

METHODS

A retrospective cohort study was conducted using the Texas Cancer Registry (TCR) database. The cohort comprised of adult (≥ 18 years) patients with metastatic melanoma diagnosed between June 2011 and December 2018. The trend in immunotherapy utilization was assessed by determining the proportion of patients receiving immunotherapy each year. The Average Annual Percent Change (AAPC) in immunotherapy utilization was assessed using joinpoint regression, while multivariable logistic regression was used to determine the association between patient characteristics and immunotherapy receipt.

RESULTS

A total of 1,795 adult patients with metastatic melanoma were identified from the TCR. Immunotherapy utilization was higher among younger patients, those with no comorbidities, and patients with private insurance. Multivariable analysis showed that the likelihood of receipt of immunotherapy decreased with older age [(adjusted Odds Ratio (aOR), 0.92; 95% CI, 0.89- 0.93, p = 0.001], living in high poverty neighborhood (aOR, 0.52; 95% CI, 0.44 - 0.66, p < 0.0001), having Medicaid (aOR, 0.58; 95% CI, 0.44 - 0.73, p = 0.02), being uninsured (aOR, 0.49; 95% CI, 0.31 - 0.64, p = 0.01), and having comorbidities (CCI score 1: aOR, 0.48; 95% CI, 0.34 - 0.71, p = 0.003; CCI score ≥ 2: aOR, 0.32; 95% CI, 0.16 - 0.56, p < 0.0001).

CONCLUSIONS AND RELEVANCE

This cohort study identified sociodemographic and socioeconomic disparities in access to immunotherapy in Texas, highlighting the need for policies such as Medicaid expansion that would increase equitable access to this innovative therapy.

The Affordable Care Act and suicide incidence among adults with cancer

BACKGROUND

Patients with cancer are at an increased suicide risk, and socioeconomic deprivation may further exacerbate that risk. The Affordable Care Act (ACA) expanded insurance coverage options for low-income individuals and mandated coverage of mental health care. Our objective was to quantify associations of the ACA with suicide incidence among patients with cancer.

METHODS

We identified US patients with cancer aged 18-74 years diagnosed with cancer from 2011 to 2016 from the Surveillance, Epidemiology, and End Results database. The primary outcome was the 1-year incidence of suicide based on cumulative incidence analyses. Difference-in-differences (DID) analyses compared changes in suicide incidence from 2011-2013 (pre-ACA) to 2014-2016 (post-ACA) in Medicaid expansion relative to non-expansion states. We conducted falsification tests with 65-74-year-old patients with cancer, who are Medicare-eligible and not expected to benefit from ACA provisions.

RESULTS

We identified 1,263,717 patients with cancer, 812 of whom died by suicide. In DID analyses, there was no change in suicide incidence after 2014 in Medicaid expansion vs. non-expansion states for nonelderly (18-64 years) patients with cancer (p = .41), but there was a decrease in suicide incidence among young adults (18-39 years) (- 64.36 per 100,000, 95% CI =  - 125.96 to - 2.76, p = .041). There were no ACA-associated changes in suicide incidence among 65-74-year-old patients with cancer.

CONCLUSIONS

We found an ACA-associated decrease in the incidence of suicide for some nonelderly patients with cancer, particularly young adults in Medicaid expansion vs. non-expansion states. Expanding access to health care may decrease the risk of suicide among cancer survivors.

Evaluating Medicaid expansion benefits for patients with cancer: National Cancer Database analysis and systematic review

BACKGROUND

Insurance status modifies healthcare access and inequities. The Affordable Care Act expanded Medicaid coverage for people with low incomes in the United States. This study assessed the consequences of this policy change for cancer care after expansion in 2014.

METHODS

National Cancer Database (NCDB) public benchmark reports were queried for each malignancy in 2013 and 2016. Furthermore, a systematic search [PubMed, Embase, Scopus and Cochrane] was performed. Data on insurance status, access to cancer screening and treatment, and socioeconomic disparities in these metrics was collected.

RESULTS

Two-tailed analysis of the NCDB revealed that 14 out of 18 eligible states had a statistically significant increase in Medicaid-insured patients with cancer after expansion. The average percentage increase was 51 % (13.2-204 %). From the systematic review, 229 studies were identified, 26 met inclusion. All 21 relevant articles reported lower uninsured rates. The average increase of Medicaid-insured patients was 77 % (9.5-230 %) and the average decrease of uninsured rates was 55 % (13.4-73 %). 15 out of 21 articles reported increased access to care. 16 out of 17 articles reported reductions in inequities.

CONCLUSION

Medicaid expansion in 2014 increased the number of insured patients with cancer. Expansion also improved access to screening and treatment in most oncologic care, and reduced socioeconomic disparities. Further studies evaluating correlative survival outcomes are needed.

POLICY SUMMARY

This study informs debates on expansion of Medicaid in state governments and electorates in the United States, and on health insurance reform broadly, by providing insight into how health insurance can benefit people with cancer while revealing how less insurance coverage could harm patients with cancer before and after their diagnosis. This study also contributes to discussions of health insurance mandates, subsidized coverage for people with low incomes, and covered healthcare services determinations by public and private health insurance providers in other countries.

Association of Sociodemographic Factors With Immunotherapy Receipt for Metastatic Melanoma in the US

IMPORTANCE

Strides to improve survival in metastatic melanoma have been made with the use of immunotherapeutic agents in the form of immune checkpoint inhibitors.

OBJECTIVE

To examine the factors associated with immunotherapy receipt in patients with metastatic melanoma in the era of immune checkpoint inhibitors and the Patient Protection and Affordable Care Act.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data on 9882 patients with metastatic melanoma diagnosed from January 1, 2013, to December 31, 2016, from the National Cancer Database. Patients who did not have documentation regarding immunotherapy receipt were excluded. Data analysis was performed from July 1, 2019, to December 15, 2019.

EXPOSURE

Receipt of immunotherapy.

MAIN OUTCOMES AND MEASURES

The primary outcome was the association of receipt of immunotherapy as first-line therapy with sociodemographic factors. The secondary outcome was overall survival by receipt of immunotherapy.

RESULTS

A total of 9512 patients (mean [SD] age, 65.1 [14.4] years; 6481 [68.1%] male; 9217 [96.9%] White) met the criteria for treatment analysis. A total of 3428 (36.0%) received immunotherapy, and 6084 (64.0%) did not. Increasing age (odds ratio [OR], 0.98; 95% CI, 0.97-0.98; P < .001) and increasing Charlson-Deyo comorbidity index (OR, 0.86; 95% CI, 0.80-0.92; P < .001) were associated with lower odds of receiving immunotherapy on regression analysis. Diagnosis in Medicaid expansion states (OR, 1.16; 95% CI, 1.05-1.27; P = .003), treatment at an academic or integrated cancer network program (OR, 1.59; 95% CI, 1.45-1.75; P < .001), and residence within the highest quartile of high school graduation rate zip code area (OR, 1.31; 95% CI, 1.09-1.56; P = .003) were associated with an increased likelihood of receiving immunotherapy. Median overall survival was 10.1 months (95% CI, 9.6-10.6 months) among all patients. Patients who received first-line immunotherapy had a median overall survival of 18.4 months (95% CI, 16.6-20.1 months) compared with 7.5 months (95% CI, 7.0-7.9 months) (P < .001) among patients who did not.

CONCLUSIONS AND RELEVANCE

In this cohort study, patients who received immunotherapy for metastatic melanoma had improved overall survival. Residence in Medicaid expansion states, younger age, low comorbidity index, care at academic medical centers or integrated network cancer programs, and residence in zip codes within the highest quartile of high school graduation were associated with an increased likelihood of receiving immunotherapy. Recognizing sociodemographic associations with treatment receipt is important to identify potential barriers to treatment.

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.

State Medicaid expansion status, insurance coverage and stage at diagnosis in head and neck cancer patients

OBJECTIVES

Only one in three head and neck cancer (HNC) patients present with early-stage disease. We aimed to quantify associations between state Medicaid expansions and changes in insurance coverage rates and stage at diagnosis of HNC.

METHODS

Using a quasi-experimental difference-in-differences (DID) approach and data from 26,330 cases included in the Surveillance, Epidemiology, and End Results program (2011-2015), we retrospectively examined changes in insurance coverage and stage at diagnosis of adult HNC in states that expanded Medicaid (EXP) versus those that did not (NEXP).

RESULTS

There was a significant increase in Medicaid coverage in EXP (+1.6 percentage point (PP) versus) vs. NEXP (-1.8 PP) states (3.36 PP, 95% CI = 1.32, 5.41; p = 0.001), and this increase was mostly among residents of low income and education counties. We also observed a reduction in uninsured rates among HNC patients in low income counties (-4.17 PP, 95% CI = -6.84, -1.51; p = 0.002). Overall, early stage diagnosis rates were 28.3% (EXP) vs. 26.7% (NEXP), with significant increases in early stage diagnosis post-Medicaid expansion among young adults, 18-34 years (17.2 PP, 95% CI - 1.34 to 33.1, p = 0.034), females (7.54 PP, 95% CI = 2.00 to 13.10, p = 0.008), unmarried patients (3.83 PP, 95% CI = 0.30-7.35, p = 0.033), and patients with lip cancer (13.5 PP, 95% CI = 2.67-24.3, p = 0.015).

CONCLUSIONS

Medicaid expansion is associated with improved insurance coverage rates for HNC patients, particularly those with low income, and increases in early stage diagnoses for young adults and women.

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

BACKGROUND

To the authors' knowledge, little is known regarding the impact of the Patient Protection and Affordable Care Act (ACA) on people living with HIV and cancer (PLWHC), who have lower cancer treatment rates and worse cancer outcomes. To investigate this research gap, the authors examined the effects of the ACA on insurance coverage and receipt of cancer treatment among PLWHC in the United States.

METHODS

HIV-infected individuals aged 18 to 64 years old with cancer diagnosed between 2011 and 2015 were identified in the National Cancer Data Base. Health insurance coverage and cancer treatment receipt were compared before and after implementation of the ACA in non-Medicaid expansion and Medicaid expansion states using difference-in-differences analysis.

RESULTS

Of the 4794 PLWHC analyzed, approximately 49% resided in nonexpansion states and were more often uninsured (16.7% vs 4.2%), nonwhite (65.2% vs 60.2%), and of low income (36.3% vs 26.9%) compared with those in Medicaid expansion states. After 2014, the percentage of uninsured individuals decreased in expansion states (from 4.9% to 3%; P = .01) and nonexpansion states (from 17.6% to 14.6%; P = .06), possibly due to increased Medicaid coverage in expansion states (from 36.9% to 39.2%) and increased private insurance coverage in nonexpansion states (from 29.5% to 34.7%). There was no significant difference in cancer treatment receipt noted between Medicaid expansion and nonexpansion states. However, the percentage of PLWHC treated at academic facilities increased significantly only in expansion states (from 40.2% to 46.7% [P < .0001]; difference-in-differences analysis: 7.2 percentage points [P = .02]).

CONCLUSIONS

The implementation of the ACA was associated with improved insurance coverage among PLWHC. Lack of insurance still is common in non-Medicaid expansion states. Patients with minority or low socioeconomic status more often resided in nonexpansion states, thereby highlighting the need for further insurance expansion.

The Impact of the Affordable Care Act on Disparities in Private and Medicaid Insurance Coverage Among Patients Under 65 With Newly Diagnosed Cancer

PURPOSE

To investigate the impact of the Affordable Care Act on racial and rural-urban disparities in insurance coverage for patients under age 65 with cancer.

METHODS AND MATERIALS

Using the Surveillance, Epidemiology, and End Results data from 2011 to 2015, we calculated the proportions of uninsured, Medicaid, and non-Medicaid insured (including private insurance) patients before and after the Medicaid expansion. We calculated the absolute percent change and difference in differences (DiD) to evaluate whether the Medicaid expansion had an impact on the distribution of types of insurance. Adjusted DiD analyses accounted for age, race, sex, county-level median household income, and rural-urban residence.

RESULTS

There was a greater decrease in uninsured rate in expansion states (-3.0%) versus nonexpansion states (-0.9%, DiD -2.1%), particularly among Black (DiD -3.4%), Hispanic (-3.9%), and rural patients (-4.8%). In expansion states, an increase in the proportion of patients with Medicaid coincided with a decrease in the proportion with non-Medicaid insurance; the opposite was observed in nonexpansion states. The decrease in non-Medicaid insurance varied by patient race: Asian/Pacific Islanders (adjusted DiD -9.7%), Hispanic (-4.2%), non-Hispanic black (-4.0%), and non-Hispanic white (-2.8%).

CONCLUSIONS

Medicaid expansion versus nonexpansion states observed a slightly greater reduction in the uninsured rate, but Medicaid expansion states also observed a corresponding shift from non-Medicaid (including private) to Medicaid insurance, which may paradoxically exacerbate disparities in access to care and cancer outcomes. Long-term outcomes and continued study are required to fully understand the impact of the Affordable Care Act on disparities in cancer care.

Impacts of the Affordable Care Act Dependent Coverage Provision on Young Adults With Cancer

INTRODUCTION

Evidence through 2012 suggests that the 2010 Affordable Care Act Dependent Coverage Provision, extending dependent insurance coverage eligibility to age 26years, increased young adult insurance coverage and decreased cancer diagnosis stage in young adult cancer patients. This study examines Dependent Coverage Provision-associated changes in insurance coverage and diagnosis stage through 2014 in young adult cancer patients.

METHODS

Using a quasi-experimental study design, analyses were conducted in 2017-2018 using 2007 to 2014 data from the Surveillance, Epidemiology, and End Results (SEER) 18 and the National Cancer Database (NCDB). Using difference-in-differences analyses applied to linear probability models, changes in the percentage of policy-eligible individuals aged 19-25years versus ineligible individuals aged 27-29years who were insured (excluding Medicaid) and diagnosed at early (Stages 0 and 1) or late (Stage 4) stages following Dependent Coverage Provision enactment were estimated.

RESULTS

A total of 36,901 and 92,358 young adults were included from SEER and NCDB. Consistent increases in the percentage insured (SEER: 3.45 percentage points, 95% CI=2.04, 4.87; NCDB: 3.72 percentage points, 95% CI=2.80, 4.64); variable increases in early-stage diagnoses (2.25 percentage points, 95% CI=0.40, 4.10; 0.69 percentage points, 95% CI= -0.65, 2.02); and decreases in late-stage diagnoses (-1.74 percentage points, 95% CI= -3.10, -0.38; -0.58 percentage points, 95% CI= -1.46, 0.30) were observed in young adults aged 19-25 versus 27-29years.

CONCLUSIONS

These results provide clear evidence for a Dependent Coverage Provision-associated impact on insurance coverage in young adult cancer patients; however, clear impacts on diagnosis stage are less evident.

Effect of health disparities on overall survival of patients with glioblastoma

BACKGROUND

Examine the potential effects of health disparities in survival of glioblastoma (GB) patients.

METHODS

We conducted a retrospective chart review of newly diagnosed GB patients from 2000 to 2015 at a free standing dedicated cancer center (MD Anderson Cancer Center-MDACC) and a safety net county hospital (Ben Taub General Hospital-BT) located in Houston, Texas. We obtained demographics, insurance status, extent of resection, treatments, and other known prognostic variables (Karnofsky Score-KPS) to evaluate their role on overall GB survival (OS).

RESULTS

We identified 1073 GB patients consisting of 177 from BT and 896 from MDACC. We found significant differences by ethnicity, insurance status, KPS at diagnosis, extent of resection, and percentage of patients receiving standard of care (SOC) between the two centers. OS was 1.64 years for MDACC patients and 1.24 years for BT patients (p < 0.0176). Only 81 (45.8%) BT patients received SOC compared to 577 (64%) of MDACC patients (p < 0.0001). However, there was no significant difference in OS for patients who received SOC, 1.84 years for MDACC patients and 1.99 years for BT patients (p < 0.4787). Of the 96 BT patients who did not receive SOC, 29 (30%) had KPS less than 70 at time of diagnosis and 77 (80%) lacked insurance.

CONCLUSIONS

GB patients treated at a safety net county hospital had similar OS compared to a free standing comprehensive cancer center when receiving SOC. County hospital patients had poorer KPS at diagnosis and were often lacking health insurance affecting their ability to receive SOC.

Changes in insurance coverage for cancer patients receiving brachytherapy before and after enactment of the Affordable Care Act

PURPOSE

The Patient Protection and Affordable Care Act called for expansion of Medicaid in 2014. As some states elected to expand Medicaid and others did not, the goal of this study was to determine the effect of Medicaid expansion on the insurance status at cancer diagnosis of brachytherapy patients.

METHODS AND MATERIALS

Patients aged 19-64 years with breast, cervical, uterine, or prostate cancer treated with brachytherapy from 2011 to 2014 with known insurance status were identified within the Surveillance, Epidemiology, and End Results registry. Fisher's exact test was used to test for associations of insurance status with expanded versus nonexpanded states. For multivariate analysis, a binomial logistic regression was performed, dichotomized to uninsured versus any insurance.

RESULTS

Fifteen thousand four hundred ninety-seven subjects met entry criteria. In the entire cohort, rates of uninsurance were higher in nonexpanded states at baseline (4.5% vs. 2.9%, p < 0.00001). With selective Medicaid expansion in 2014, expanded states had a reduction in uninsurance rates (2.9-1.8%, p = 0.026), whereas nonexpanded states had a nonsignificant increase in uninsurance (4.5-5.0%, p = 0.371). There was a reduction in uninsurance in expanded states in areas of highest poverty (2.9-1.1%, p = 0.0004) not seen in nonexpanded states. These associations remained significant on multivariate analysis (OR 2.2, 95% CI 1.8-2.8, p < 0.00001).

CONCLUSIONS

Patients who received brachytherapy were less likely to be uninsured in states where Medicaid was expanded, particularly evident in regions with highest poverty levels. These results should help inform policy decisions and efforts to ensure that all patients have access to high quality treatments, such as brachytherapy.