Bladder Cancer Following Medicaid Expansion: No Changes in the Diagnosis of Muscle-Invasive Disease and Time to Treatment

Abstract

BACKGROUND: Bladder cancer patients who are insured experience improved outcomes. Medicaid expansion aimed to increase insurance coverage and improve access to care. However, the association between Medicaid expansion and stage at diagnosis or time to treatment for those with advanced bladder cancer is unknown. OBJECTIVE: We sought to determine to association of Medicaid expansion with stage at diagnosis, and time to treatment for patients with muscle-invasive bladder cancer. METHODS: A US-based cancer registry was utilized to evaluate the association between Medicaid expansion and cancer stage at diagnosis, insurance rates, and time to treatment (>60 days from diagnosis) for those diagnosed with bladder cancer. We compared outcomes in non-Medicare-aged patients in non-expansion states (n = 16,602) and expansion states (n = 15,921) before (years 2012-2013) and after (years 2015-2016) Medicaid expansion with adjusted difference-indifferences (DIDs) using multivariable linear regression. RESULTS: The DIDs of percentage of bladder cancer patients with Stage ≥ II disease (0.02%; 95% confidence interval [CI]-1.91 to 1.95%, p = 0.9), without insurance (-0.65%; 95% CI-1.71 to 0.41), and with metastatic disease at diagnosis (-0.07%; 95% CI-1.14 to 1.00, both p > 0.10) did not change following insurance expansion despite an increase in Medicaid coverage (6.03%; 95% CI 4.79 to 7.29, p < 0.01). Any treatment with either cystectomy, radiation or systemic therapy > 60 days after diagnosis of stage ≥ II disease did not change (DID 1.48%; 95% CI-3.29 to 6.25%, p = 0.50). On subgroup analysis of patients living in low-income regions, the rates of stage ≥ II disease, no insurance, metastatic disease, and time to treatment did not significantly change. CONCLUSION: Medicaid expansion was not associated with changes in advanced cancer stage at diagnosis or time to treatment in newly diagnosed bladder cancer patients.

Effect of Medicaid expansion on cancer treatment and survival among Medicaid beneficiaries and the uninsured

“…32,39,40 Although prior work has examined the association between ME, timely treatment, and cancer survival, most of these studies have included all insurance types in their study cohort, which could mask the impact of the policy on Medicaid eligible patients who are most likely to benefit from ME. [18][19][20]32,38,41 By focusing our analysis on Medicaid and uninsured patients, we provide a more granular and arguably more precise estimate of the policy's effect on its target population. In our analysis of Medicaid and uninsured patients, the DID estimates for TTI and OS are larger in magnitude compared to previous studies that included all insurance types in their analysis of ME.…”

“…Additional studies using other data sources (including SEER or NAACCR) have found small improvements in 2‐year OS for lung and colorectal cancer associated with ME, but no significant changes for patients with breast or cervical cancer 32,39,40 . Although prior work has examined the association between ME, timely treatment, and cancer survival, most of these studies have included all insurance types in their study cohort, which could mask the impact of the policy on Medicaid eligible patients who are most likely to benefit from ME 18–20,32,38,41 . By focusing our analysis on Medicaid and uninsured patients, we provide a more granular and arguably more precise estimate of the policy's effect on its target population.…”

Access to Urological Care for Medicaid-Insured Patients at Urology Practices Acquired by Private Equity Firms

“…For example, hospital-registry based studies of patients with genitourinary cancers derived from the National Cancer Database largely show declines in the rate of uninsurance following Medicaid expansion, but report variations in changes to stage of diagnosis and time to treatment. 13,[17][18][19][20] Appreciating the persistence of barriers to access elevates the importance of conducting studies at the level of the Medicaid insured population.…”