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Demkowicz PC, Buck MB, Nie J, Marks VA, Wheeler SB, Dinan MA, Gross CP, Leapman MS. Changes in Facility Share of Medicaid-insured Patients With Urologic Cancers Following Implementation of the Patient Protection and Affordable Care Act. Urology 2024:S0090-4295(24)00447-3. [PMID: 38901803 DOI: 10.1016/j.urology.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 05/19/2024] [Accepted: 06/04/2024] [Indexed: 06/22/2024]
Abstract
OBJECTIVE To examine Medicaid-insurance acceptance at facilities treating urologic cancers following implementation of the Affordable Care Act (ACA). METHODS We conducted a retrospective, longitudinal study with a pre-post design. We accessed 2010-2017 data from the National Cancer Database, calculating the facility-level change in proportion of urologic cancer patients with Medicaid following implementation of the ACA. We used multivariable logistic regression to assess baseline clinical and demographic factors associated with changes in the proportion of patients at a facility insured through Medicaid. RESULTS We identified 630 facilities, including 287 in Medicaid expansion states and 343 in non-expansion states associated with 436,082 urologic cancer patients. The mean facility-level change in proportion of patients with Medicaid was + 5.8% (95% CI 5.0%-6.5%) in expansion states versus + 0.6% (95% CI 0.2%-0.9%) in non-expansion states. There were 179 facilities that experienced a decrease in the post-ACA period, representing 13.6% of facilities in expansion states and 40.8% in non-expansion states (P <.001). Factors associated with a decrease in proportion of urologic cancer patients insured by Medicaid included non-expansion state status (OR 8.9, 95% CI 5.3-15.6, P <.001), higher baseline proportion of patients with Medicaid (highest quartile vs lowest: OR 4.6, 95% CI 2.3-9.4, P <.001) and high-income zip code (highest vs lowest quartile: OR 3.1, 95% CI 1.5-6.6, P <.001). CONCLUSION Urologic cancer care for Medicaid-insured Americans remains unevenly distributed across cancer care centers, even in states that expanded coverage. Our findings suggest that this variation may reflect the effort of some facilities to reduce their financial exposure to increased numbers of Medicaid patients in the wake of ACA-supported state expansions.
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Affiliation(s)
| | - Matthew B Buck
- Department of Urology, Sidney Kimmel Medical College, Philadelphia, PA
| | - James Nie
- Department of Urology, University of California San Francisco, San Francisco, CA
| | | | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michaela A Dinan
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT
| | - Cary P Gross
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT
| | - Michael S Leapman
- Department of Urology, Yale School of Medicine, New Haven, CT; Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT.
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Shah YB, Goldberg H, Hu B, Daneshmand S, Chandrasekar T. Metastatic Testicular Cancer Patterns and Predictors: A Contemporary Population-based SEER Analysis. Urology 2023; 180:182-189. [PMID: 37467809 DOI: 10.1016/j.urology.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 05/12/2023] [Accepted: 07/03/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVE To elucidate clinical and demographic predictors of metastatic testicular cancer (TC) at presentation and study the impact of these factors on prognosis. Patients with metastatic TC experience poorer outcomes than those with localized or locoregional disease. Social determinants of health may compound this trend. METHODS The Surveillance, Epidemiology, and End Results (SEER) database was queried to identify 16,528 patients aged ≥18 with TC diagnosed from 2010 to 2016. Descriptive statistics were analyzed using Fisher exact test and Pearson chi-square test for continuous and categorical variables. Predictors of specific metastases and factors impacting cancer-specific mortality (CSM) were evaluated using multivariate logistic regression analysis and competing risks regression, respectively. RESULTS Of 16,474 patients with complete data, 1877 (11.39%) had distant metastases at diagnosis. These patients more commonly featured disease-specific and demographic variables associated with worse health outcomes (all P < .001). Lung metastases were the predominant site of synchronous and solitary metastases. Disease-specific predictors of metastasis included T stage, histology, tumor size, lymphovascular invasion, and cryptorchidism. Patient-specific predictors included age, geography, ethnicity, race, marital status, and socioeconomic status. Nearly one-fourth of patients with metastases died. Poor CSM was predicted by histology, age, insurance status, and socioeconomic status. All metastatic sites except bone were associated with worse CSM, with lung metastases conferring the greatest risk. CONCLUSION This cross-sectional study identifies variables associated with TC metastasis and survival, particularly highlighting the importance of social determinants of health in TC mortality. These findings can facilitate a risk-stratified approach to staging and management while supporting new approaches to target disparities.
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Affiliation(s)
- Yash B Shah
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Hanan Goldberg
- Department of Urology, State University of New York Upstate, Syracuse, NY
| | - Brian Hu
- Department of Urology, Loma Linda University, Loma Linda, CA
| | - Siamak Daneshmand
- Aresty Department of Urology, USC/Norris Comprehensive Cancer Center, Los Angeles, CA
| | - Thenappan Chandrasekar
- Department of Urology, Thomas Jefferson University, Philadelphia, PA; Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA; Department of Urology, University of California, Davis, Sacramento, CA.
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Marks VA, Hsiang WR, Nie J, Demkowicz P, Umer W, Haleem A, Galal B, Pak I, Kim D, Salazar MC, Berger ER, Boffa DJ, Leapman MS. Acceptance of Simulated Adult Patients With Medicaid Insurance Seeking Care in a Cancer Hospital for a New Cancer Diagnosis. JAMA Netw Open 2022; 5:e2222214. [PMID: 35838668 PMCID: PMC9287756 DOI: 10.1001/jamanetworkopen.2022.22214] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
IMPORTANCE Although there have been significant increases in the number of US residents insured through Medicaid, the ability of patients with Medicaid to access cancer care services is less well known. OBJECTIVE To assess facility-level acceptance of Medicaid insurance among patients diagnosed with common cancers. DESIGN, SETTING, AND PARTICIPANTS This national cross-sectional secret shopper study was conducted in 2020 in a random sample of Commission on Cancer-accredited facilities in the United States using a simulated cohort of Medicaid-insured adult patients with colorectal, breast, kidney, and melanoma skin cancer. EXPOSURES Telephone call requesting an appointment for a patient with Medicaid with a new cancer diagnosis. MAIN OUTCOMES AND MEASURES Acceptance of Medicaid insurance for cancer care. Descriptive statistics, χ2 tests, and multivariable logistic regression models were used to examine factors associated with Medicaid acceptance for colorectal, breast, kidney, and skin cancer. High access hospitals were defined as those offering care across all 4 cancer types surveyed. Explanatory measures included facility-level factors from the 2016 American Hospital Association Annual Survey and Centers for Medicare & Medicaid Services General Information database. RESULTS A nationally representative sample of 334 facilities was created, of which 226 (67.7%) provided high access to patients with Medicaid seeking cancer care. Medicaid acceptance differed by cancer site, with 319 facilities (95.5%) accepting Medicaid insurance for breast cancer care; 302 (90.4%), colorectal; 290 (86.8%), kidney; and 266 (79.6%), skin. Comprehensive community cancer programs (OR, 0.4; 95% CI, 0.2-0.7; P = .007) were significantly less likely to provide high access to care for patients with Medicaid. Facilities with nongovernment, nonprofit (vs for-profit: OR, 3.5; 95% CI, 1.1-10.8; P = .03) and government (vs for-profit: OR, 6.6; 95% CI, 1.6-27.2; P = .01) ownership, integrated salary models (OR, 2.6; 95% CI, 1.5-4.5; P = .001), and average (vs above-average: OR, 6.4; 95% CI, 1.4-29.6; P = .02) or below-average (vs above-average: OR, 8.4; 95% CI, 1.5-47.5; P = .02) effectiveness of care were associated with high access to Medicaid. State Medicaid expansion status was not significantly associated with high access. CONCLUSIONS AND RELEVANCE This study identified access disparities for patients with Medicaid insurance at centers designated for high-quality care. These findings highlight gaps in cancer care for the expanding population of patients receiving Medicaid.
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Affiliation(s)
- Victoria A. Marks
- Department of Urology, Yale School of Medicine, New Haven, Connecticut
| | - Walter R. Hsiang
- Department of Urology, Yale School of Medicine, New Haven, Connecticut
- University of California San Francisco
| | - James Nie
- Department of Urology, Yale School of Medicine, New Haven, Connecticut
| | - Patrick Demkowicz
- Department of Urology, Yale School of Medicine, New Haven, Connecticut
| | | | | | | | - Irene Pak
- Yale University, New Haven, Connecticut
| | - Dana Kim
- Yale University, New Haven, Connecticut
| | | | | | - Daniel J. Boffa
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Michael S. Leapman
- Department of Urology, Yale School of Medicine, New Haven, Connecticut
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut
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Predictive factors of diagnostic delay and effect on treatment patterns in testicular germ cell tumor patients. Urol Oncol 2022; 40:201.e1-201.e7. [DOI: 10.1016/j.urolonc.2022.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/28/2022] [Accepted: 02/26/2022] [Indexed: 11/21/2022]
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Toboni MD, Cohen A, Gentry ZL, Ostby SA, Wang Z, Bae S, Leath C. Sociodemographic characteristics and cervical cancer survival in different regions of the United States: a National Cancer Database study. Int J Gynecol Cancer 2022; 32:724-731. [DOI: 10.1136/ijgc-2021-003227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
ObjectiveTo determine how sociodemographic factors impact cervical cancer survival in different geographic locations in the USA.MethodsA retrospective cohort of patients with cervical cancer from January 1, 2004 to December 31, 2015 in the National Cancer Database (NCDB) was identified. Tumor characteristics as well as race, income, insurance type, and treating facility types were compared among nine geographic regions. χ2 tests and Cox regression were used to compare differences between regions; p values <0.05 were considered significant.ResultsA total of 48 787 patients were included. Survival was inferior in seven of nine regions for underinsured patients. In six regions survival was inferior for Medicaid and Medicare patients, respectively: Middle Atlantic: hazard ratio (HR) 1.25 and 1.22; South Atlantic: HR 1.41 and HR 1.22; East North Central: HR 1.36 and HR 1.25; East South Central: HR 1.37 and HR 1.25; West North Central: HR 1.67 and HR 1.42; West South Central: HR 1.44 and HR 1.46. In the Pacific region survival was inferior for Medicare patients (HR 1.35) but not inferior for Medicaid patients. Being uninsured was associated with worse survival in the South Atlantic (HR 1.23), East North Central (HR 1.23), East South Central (HR 1.56), and West South Central (HR 1.31) regions. Annual income level under $38 000 was associated with worse survival in the Middle Atlantic (HR 1.24), South Atlantic (HR 1.35), and East North Central (HR 1.49) regions. Lastly, when compared with academic research institutions, comprehensive community cancer centers had significantly worse survival in four of the nine regions.ConclusionsCervical cancer mortality is higher for women with a low income, underinsured (Medicaid or Medicare) or uninsured status, and decreased access to academic institutions in most US regions. An increase in cervical cancer mortality was associated with underinsured or uninsured populations in regions mainly located in the South and Midwest.
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Nie J, Hsiang W, Marks V, Laditi F, Varghese A, Umer W, Haleem A, Mothy D, Wang H, Patel R, Pan W, Shah R, Khan S, Singh R, Golla V, Cavallo J, Breyer BN, Leapman MS. Access to Urological Care for Medicaid-Insured Patients at Urology Practices Acquired by Private Equity Firms. Urology 2022; 164:112-117. [PMID: 35276202 DOI: 10.1016/j.urology.2022.01.055] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 12/29/2021] [Accepted: 01/02/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To characterize appointment access for Medicaid-insured patients seeking care at urology practices affiliated with private equity firms in light of the recent national trends in practice consolidation. METHODS We identified 214 urology offices affiliated with private equity firms that were geographically matched with 231 non-private equity affiliated urology offices. Using a standardized script, researchers posed as an adult patient with either Medicaid or commercial insurance in the clinical setting of new onset, painless hematuria. The primary outcome was whether the patient's insurance was accepted for an appointment. The secondary outcome was appointment wait time. RESULTS We conducted 815 appointment inquiry calls to 214 PE and 231 non-PE-affiliated urology offices across 12 states. Appointment availability was higher for commercially-insured patients (99.0%; 95% CI: 98.1%-99.9%) versus Medicaid-insured patients (59.8%; 95% CI: 55.0%-64.6%) (p<0.0001). Medicaid acceptance was higher at non-PE affiliated (66.8%; CI 60.4%-73.2%) than PE-affiliated practices (52.1%; 95% CI 45.0%-59.2%) (p=0.003). On multivariable logistic regression analysis, state Medicaid expansion status (OR 2.20; CI 1.14-4.28; p=0.020) was independently associated with Medicaid appointment availability, whereas PE-affiliation (OR 0.55; CI 0.37-0.83; p=0.004) was independently associated with lower Medicaid access. Appointment wait times did not differ significantly for commercially-insured versus Medicaid patients (19.2 vs 20.1 days; p=0.59), but PE-affiliated practices offered shorter mean wait times than non-PE offices (17.5 vs 21.4 days; p=0.017). CONCLUSIONS Access disparities for urologic evaluation in patients with Medicaid insurance at urology practices and were more pronounced at private equity acquired practices.
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Affiliation(s)
- James Nie
- Department of Urology, Yale University School of Medicine, New Haven, CT, USA; Yale University School of Medicine, New Haven, CT, USA
| | - Walter Hsiang
- Department of Urology, University of California-San Francisco, San Francisco, CA, USA
| | - Victoria Marks
- Department of Urology, Yale University School of Medicine, New Haven, CT, USA; Yale University School of Medicine, New Haven, CT, USA
| | - Folawiyo Laditi
- Department of Urology, Yale University School of Medicine, New Haven, CT, USA; Yale University School of Medicine, New Haven, CT, USA
| | - Adarsh Varghese
- Department of Urology, Yale University School of Medicine, New Haven, CT, USA
| | - Waez Umer
- Department of Urology, Yale University School of Medicine, New Haven, CT, USA
| | - Afash Haleem
- Department of Urology, Yale University School of Medicine, New Haven, CT, USA
| | - David Mothy
- Department of Urology, Yale University School of Medicine, New Haven, CT, USA
| | - Hannah Wang
- Department of Urology, Yale University School of Medicine, New Haven, CT, USA
| | - Riya Patel
- Department of Urology, Yale University School of Medicine, New Haven, CT, USA
| | - William Pan
- Department of Urology, Yale University School of Medicine, New Haven, CT, USA
| | - Rishi Shah
- Department of Urology, Yale University School of Medicine, New Haven, CT, USA
| | - Sophia Khan
- Department of Urology, Yale University School of Medicine, New Haven, CT, USA
| | - Rohan Singh
- Department of Urology, Yale University School of Medicine, New Haven, CT, USA
| | | | - Jaime Cavallo
- Department of Urology, Yale University School of Medicine, New Haven, CT, USA; Yale University School of Medicine, New Haven, CT, USA
| | - Benjamin N Breyer
- Department of Urology, University of California-San Francisco, San Francisco, CA, USA
| | - Michael S Leapman
- Department of Urology, Yale University School of Medicine, New Haven, CT, USA; Yale University School of Medicine, New Haven, CT, USA.
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Meng X, Vazquez L, Howard JM, Kenigsberg AP, Singla N, Margulis V, Bagrodia A, Lotan Y, Xi Y, Woldu SL. The early impact of medicaid expansion on urologic malignancies in the United States. Urol Oncol 2021; 40:103.e1-103.e8. [PMID: 34666919 DOI: 10.1016/j.urolonc.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 08/26/2021] [Accepted: 09/07/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE To assess the effects of variable adoption of Medicaid Expansion (ME) of the Affordable Care Act among different states on urologic malignancies using a new variable that defines ME status of patient's residence in a nationwide cancer registry. BASIC PROCEDURES The National Cancer Database was queried for urologic malignancies (bladder, prostate, kidney and testis) from 2011 to 2016, spanning the period surrounding the primary ME which took place in 2014. Trends in insurance status at time of diagnosis and effects on stage at presentation and survival after ME were evaluated using a difference-in-differences estimator and stratified Cox proportional hazards regression model. MAIN FINDINGS The percentage of patients with Medicaid coverage at the time of diagnosis increased significantly after adoption of ME in ME states across all urologic malignancies. Concurrently, there was a significant decrease in percentage of uninsured patients diagnosed with testis cancer, but not other urologic malignancies, in ME states. A change in the stage at presentation was not observed across all urologic malignancies for patients in ME states after adoption of ME. No difference in overall survival was noted among patients living in a ME state compared to non-ME states with adoption of ME in 2014. PRINCIPAL CONCLUSIONS Despite increases in the proportion of patients with Medicaid coverage after 2014 in states that enrolled in ME, there was not an associated change in stage at presentation or survival for patients with genitourinary malignancy.
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Affiliation(s)
- Xiaosong Meng
- Department of Urology, UT Southwestern Medical Center, Dallas, TX
| | - Louis Vazquez
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX; Department of Statistical Science, Southern Methodist University, Dallas, TX
| | - Jeffrey M Howard
- Department of Urology, UT Southwestern Medical Center, Dallas, TX
| | | | - Nirmish Singla
- Brady Urological Institute, Johns Hopkins University, Baltimore, MD
| | - Vitaly Margulis
- Department of Urology, UT Southwestern Medical Center, Dallas, TX
| | - Aditya Bagrodia
- Department of Urology, UT Southwestern Medical Center, Dallas, TX
| | - Yair Lotan
- Department of Urology, UT Southwestern Medical Center, Dallas, TX
| | - Yin Xi
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX
| | - Solomon L Woldu
- Department of Urology, UT Southwestern Medical Center, Dallas, TX.
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Lin Y, Monnette A, Shi L. Effects of medicaid expansion on poverty disparities in health insurance coverage. Int J Equity Health 2021; 20:171. [PMID: 34311757 PMCID: PMC8314606 DOI: 10.1186/s12939-021-01486-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 06/01/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND More than 30 states have either expanded Medicaid or are actively considering expansion. The coverage gains from this policy are well documented, however, the impacts of its increasing coverage on poverty disparity are unclear at the national level. METHOD American Community Survey (2012-2018) was used to examine the effects of Medicaid expansion on poverty disparity in insurance coverage for nonelderly adults in the United States. Differences-in-differences-in-differences design was used to analyze trends in uninsured rates by poverty levels: (1) < 138 %, (2) 138-400 % and (3) > 400 % federal poverty level (FPL). RESULTS Compared with uninsured rates in 2012, uninsured rates in 2018 decreased by 10.75 %, 6.42 %, and 1.11 % for < 138 %, 138-400 %, and > 400 % FPL, respectively. From 2012 to 2018, > 400 % FPL group continuously had the lowest uninsured rate and < 138 % FPL group had the highest uninsured rate. Compared with ≥ 138 % FPL groups, there was a 2.54 % reduction in uninsured risk after Medicaid expansion among < 138 % FPL group in Medicaid expansion states versus control states. After eliminating the impact of the ACA market exchange premium subsidy, 3.18 % decrease was estimated. CONCLUSION Poverty disparity in uninsured rates improved with Medicaid expansion. However, < 138 % FPL population are still at a higher risk for being uninsured.
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Affiliation(s)
- Yilu Lin
- Department of Health Policy and Management, School of Public Health and Tropical Medicine, Tulane University, 1440 Canal Street, Suite 1900, Louisiana, 70112, New Orleans, USA
| | - Alisha Monnette
- Department of Health Policy and Management, School of Public Health and Tropical Medicine, Tulane University, 1440 Canal Street, Suite 1900, Louisiana, 70112, New Orleans, USA
| | - Lizheng Shi
- Department of Health Policy and Management, School of Public Health and Tropical Medicine, Tulane University, 1440 Canal Street, Suite 1900, Louisiana, 70112, New Orleans, USA.
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Barnes JM, Johnson KJ, Adjei Boakye E, Schapira L, Akinyemiju T, Park EM, Graboyes EM, Osazuwa-Peters N. Early Medicaid Expansion and Cancer Mortality. J Natl Cancer Inst 2021; 113:1714-1722. [PMID: 34259321 PMCID: PMC8634305 DOI: 10.1093/jnci/djab135] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 04/05/2021] [Accepted: 06/30/2021] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Justin M Barnes
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Kimberly J Johnson
- Brown School, Washington University in St. Louis, St. Louis, MO, USA,Siteman Cancer Center, Washington University in St. Louis, St. Louis, MO, USA
| | - Eric Adjei Boakye
- Department of Population Science and Policy, Southern Illinois University School of Medicine, Springfield, IL, USA,Simmons Cancer Institute, Springfield, IL, USA
| | - Lidia Schapira
- Department of Medicine (Oncology), Stanford University School of Medicine, Stanford, CA, USA,Stanford Cancer Institute, Stanford, CA, USA
| | - Tomi Akinyemiju
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA,Duke Cancer Institute, Duke University, Durham, NC, USA
| | - Eliza M Park
- Comprehensive Cancer Support Program, University of North Carolina, Chapel Hill, NC, USA,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Evan M Graboyes
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA,Hollings Cancer Center, Medical University of South Carolina, Charleston, SC, USA
| | - Nosayaba Osazuwa-Peters
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA,Duke Cancer Institute, Duke University, Durham, NC, USA,Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, NC, USA,Correspondence to: Nosayaba (Nosa) Osazuwa-Peters, BDS, PhD, MPH, CHES, Duke University School of Medicine, Department of Head and Neck Surgery and Communication Sciences, 40 Duke Medicine Cir, Duke South Yellow Zone 4080, DUMC 3805, Durham, NC 27710-4000, USA (e-mail: )
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Javier-DesLoges JF, Yuan J, Soliman S, Hakimi K, Meagher MF, Ghali F, Hsiang W, Patel DN, Kim SP, Murphy JD, Parsons JK, Derweesh IH. Evaluation of Insurance Coverage and Cancer Stage at Diagnosis Among Low-Income Adults With Renal Cell Carcinoma After Passage of the Patient Protection and Affordable Care Act. JAMA Netw Open 2021; 4:e2116267. [PMID: 34269808 PMCID: PMC8285737 DOI: 10.1001/jamanetworkopen.2021.16267] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
IMPORTANCE The association of the Patient Protection and Affordable Care Act (ACA) with insurance status and cancer stage at diagnosis among patients with renal cell carcinoma (RCC) is unknown. OBJECTIVE To test the hypothesis that the ACA may be associated with increased access to care through expansion of insurance, which may vary based on income. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort analysis included patients diagnosed with RCC from January 1, 2010, to December 31, 2016, in the National Cancer Database. Data were analyzed from July 1 to December 31, 2020. The periods from 2010 to 2013 and from 2014 to 2016 were defined as pre- and post-ACA implementation, respectively. Patients were categorized as living in a Medicaid expansion state or not. EXPOSURES Implementation of the ACA. MAIN OUTCOMES AND MEASURES The absolute percentage change (APC) of insurance coverage was calculated before and after ACA implementation in expansion and nonexpansion states. Secondary outcomes included change in stage at diagnosis, difference in the rate of insurance change, and change in localized disease between expansion and nonexpansion states. Adjusted difference-in-difference modeling was performed. RESULTS The cohort included 78 099 patients (64.7% male and 35.3% female; mean [SD] age, 54.66 [6.46] years), of whom 21.2% had low, 46.2% had middle, and 32.6% had high incomes. After ACA implementation, expansion states had a lower proportion of uninsured patients (adjusted difference-in-difference, -1.14% [95% CI, -1.98% to -1.41%]; P = .005). This occurred to the greatest degree among low-income patients through the acquisition of Medicaid (APC, 11.0% [95% CI, 8.6%-13.3%]; P < .001). Implementation of the ACA was also associated with an increase in detection of stage I and II disease (APC, 4.0% [95% CI, 1.6%-6.3%]; P = .001) among low-income patients in expansion states. CONCLUSIONS AND RELEVANCE Among patients with RCC, ACA implementation was associated with an increase in insurance coverage status in both expansion and nonexpansion states for all income groups, but to a greater degree in expansion states. The proportion of patients with localized disease increased among low-income patients in both states. These data suggest that ACA implementation is associated with earlier RCC detection among lower-income patients.
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Affiliation(s)
| | - Julia Yuan
- University of California, San Diego, School of Medicine, La Jolla
| | - Shady Soliman
- University of California, San Diego, School of Medicine, La Jolla
| | - Kevin Hakimi
- University of California, San Diego, School of Medicine, La Jolla
| | | | - Fady Ghali
- Department of Urology, University of California, San Diego, School of Medicine, La Jolla
| | - Walter Hsiang
- Department of Urology, Yale University School of Medicine, New Haven, Connecticut
| | - Devin N. Patel
- Department of Urology, University of California, San Diego, School of Medicine, La Jolla
| | - Simon P. Kim
- Department of Urology, University of Colorado Anschutz School of Medicine, Denver
| | - James D. Murphy
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, School of Medicine, La Jolla
| | - J. Kellogg Parsons
- Department of Urology, University of California, San Diego, School of Medicine, La Jolla
| | - Ithaar H. Derweesh
- Department of Urology, University of California, San Diego, School of Medicine, La Jolla
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Chertack N, Baky F, Woldu S, Bagrodia A. Reply to So, now what?: Reflections on socioeconomic factors, testicular cancer, and health care accessibility. Cancer 2021; 127:1347-1348. [PMID: 33595851 DOI: 10.1002/cncr.33374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 11/03/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Nathan Chertack
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Fady Baky
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Solomon Woldu
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Aditya Bagrodia
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas
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