Evaluation of Cancer Care After Medicaid Expansion Under the Affordable Care Act

Salazar, Michelle C.; Canavan, Maureen; Walters, Samantha L.; Herrin, Jeph; Schwartz, Jason L.; Leapman, Michael

doi:10.1001/jamanetworkopen.2020.17544

Cited by 4 publications

(8 citation statements)

References 4 publications

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“…The marked increase in continuous Medicaid coverage and decrease of those who were uninsured/gained Medicaid coverage at the time of lymphoma diagnosis is consistent with recent studies in California that evaluated insurance coverage changes in AYAs with cancer in the pre‐/post‐ACA eras 15,16 . The overall decrease we observed in private insurance coverage may be, in part, due to low‐income AYAs changing from private insurance with high patient cost‐sharing (ie, deductibles, copayments and coinsurance charges) to public insurance when they become eligible for Medicaid coverage 17 …”

Section: Discussionsupporting

confidence: 86%

“…15,16 The overall decrease we observed in private insurance coverage may be, in part, due to lowincome AYAs changing from private insurance with high patient cost-sharing (ie, deductibles, copayments and coinsurance charges) to public insurance when they become eligible for Medicaid coverage. 17 Overall, we observed that AYAs with Medicaid insurance were more likely to present with Stage IV disease than privately insured AYAs, but this association was more pronounced among AYAs with Medicaid at diagnosis/uninsured or discontinuous Medicaid. Notably, when we analyzed NHL and HL separately, AYAs with continuous Medicaid were not more likely to be diagnosed with Stage IV disease than privately insured AYAs.…”

Section: Discussionmentioning

confidence: 65%

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Stage at diagnosis and survival among adolescents and young adults with lymphomas following the Affordable Care Act implementation in California

Abrahão

Cooley

Maguire

et al. 2021

Intl Journal of Cancer

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Adolescents and young adults (AYAs, 15‐39 years) are the largest uninsured population in the Unites States, increasing the likelihood of late‐stage cancer diagnosis and poor survival. We evaluated the associations between the Affordable Care Act (ACA), insurance coverage, stage at diagnosis and survival among AYAs with lymphoma. We used data from the California Cancer Registry linked to Medicaid enrollment files on AYAs diagnosed with a primary non‐Hodgkin (NHL; n = 5959) or Hodgkin (n = 5378) lymphoma pre‐ACA and in the early and full ACA eras. Health insurance was categorized as continuous Medicaid, discontinuous Medicaid, Medicaid enrollment at diagnosis/uninsurance, other public and private. We used multivariable regression models for statistical analyses. The proportion of AYAs uninsured/Medicaid enrolled at diagnosis decreased from 13.4% pre‐ACA to 9.7% with full ACA implementation, while continuous Medicaid increased from 9.3% to 29.6% during this time (P < .001). After full ACA, AYAs with NHL were less likely to be diagnosed with Stage IV disease (adjusted odds ratio [aOR] = 0.84, 95% confidence interval [CI] = 0.73‐0.97). AYAs with lymphoma were more likely to receive care at National Cancer Institute‐Designated Cancer Centers (aOR = 1.42, 95% CI = 1.28‐1.57) and had lower likelihood of death (adjusted hazard ratio = 0.54, 95% CI = 0.46‐0.63) after full ACA. However, AYAs from the lowest socioeconomic neighborhoods, racial/ethnic minority groups and those with Medicaid continued to experience worse survival. In summary, AYAs with lymphomas experienced increased access to healthcare and better clinical outcomes following Medicaid expansion under the ACA. Yet, socioeconomic and racial/ethnic disparities remain, calling for additional efforts to decrease health inequities among underserved AYAs with lymphoma.

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Section: Discussionsupporting

confidence: 86%

Section: Discussionmentioning

confidence: 65%

Stage at diagnosis and survival among adolescents and young adults with lymphomas following the Affordable Care Act implementation in California

Abrahão

Cooley

Maguire

et al. 2021

Intl Journal of Cancer

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“…Prior studies have suggested that offering after-hours care and increasing reliance on nurse practitioners may improve availability of care [ 44 ]. Policy-level interventions including the Affordable Care Act (ACA) and Medicaid expansion may also reduce the time to cancer diagnosis in the US multi-payer healthcare system, particularly for non-elderly patients and underserved populations [ 16 , 29 , 40 ]. These system-level interventions could impact the help-seeking, diagnostic, and pre-treatment MPT intervals by making it easier to schedule and pay for guideline-concordant care.…”

Section: Discussionmentioning

confidence: 99%

Pathways to ovarian cancer diagnosis: a qualitative study

et al. 2022

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Background Ovarian cancer is often diagnosed at a late stage, when survival is poor. Qualitative narratives of patients’ pathways to ovarian cancer diagnoses may identify opportunities for earlier cancer detection and, consequently, earlier stage at diagnosis. Methods We conducted semi-structured interviews of ovarian cancer patients and survivors (n = 14) and healthcare providers (n = 11) between 10/2019 and 10/2021. Interviews focused on the time leading up to an ovarian cancer diagnosis. Thematic analysis was conducted by two independent reviewers using a two-phase deductive and inductive coding approach. Deductive coding used a priori time intervals from the validated Model of Pathways to Treatment (MPT), including self-appraisal and management of symptoms, medical help-seeking, diagnosis, and pre-treatment. Inductive coding identified common themes within each stage of the MPT across patient and provider interviews. Results The median age at ovarian cancer diagnosis was 61.5 years (range, 29–78 years), and the majority of participants (11/14) were diagnosed with advanced-stage disease. The median time from first symptom to initiation of treatment was 2.8 months (range, 19 days to 4.7 years). The appraisal and help-seeking intervals contributed the greatest delays in time-to-diagnosis for ovarian cancer. Nonspecific symptoms, perceptions of health and aging, avoidant coping strategies, symptom embarrassment, and concerns about potential judgment from providers prolonged the appraisal and help-seeking intervals. Patients and providers also emphasized access to care, including financial access, as critical to a timely diagnosis. Conclusion Interventions are urgently needed to reduce ovarian cancer morbidity and mortality. Population-level screening remains unlikely to improve ovarian cancer survival, but findings from our study suggest that developing interventions to improve self-appraisal of symptoms and reduce barriers to help-seeking could reduce time-to-diagnosis for ovarian cancer. Affordability of care and insurance may be particularly important for ovarian cancer patients diagnosed in the United States.

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“…The NCDB only shares the expansion identifier for patients 40 years or older, which may have implications for studying certain cancers, particularly those with earlier age of onset. A number of other nuances could influence the impression of Medicaid expansion across the data resources (Table 3).…”

Section: Challenges To Evaluating Associations Of Medicaid Expansion ...mentioning

confidence: 99%

Understanding the Implications of Medicaid Expansion for Cancer Care in the US

et al. 2022

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Insurance status has been linked to important differences in cancer treatment and outcomes in the US. With more than 15 million individuals gaining health insurance through Medicaid expansion, there is an increasing need to understand the implications of this policy within the US cancer population. This review provides an overview of the fundamental principles and nuances of Medicaid expansion, as well as the implications for cancer care.OBSERVATIONS The Patient Protection and Affordable Care Act presented states with an option to expand Medicaid coverage by broadening the eligibility criteria (eg, raising the eligible income level). During the past 10 years, Medicaid expansion has been credited with a 30% reduction in the population of uninsured individuals in the US. Such a significant change in the insurance profile could have important implications for the 1.7 million patients diagnosed with cancer each year, the oncology teams that care for them, and policy makers. However, several factors may complicate efforts to characterize the effect of Medicaid expansion on the US cancer population. Most notably, there is considerable variation among states in terms of whether Medicaid expansion took place, when expansion occurred, eligibility criteria for Medicaid, and coverage types that Medicaid provides. In addition, economic and health policy factors may be intertwined with factors associated with Medicaid expansion. Finally, variability in the manner in which cancer care has been captured and depicted in large databases could affect the interpretation of findings associated with expansion. CONCLUSIONS AND RELEVANCEThe expansion of Medicaid was a historic public policy initiative. To fully leverage this policy to improve oncological care and to maximize learning for subsequent policies, it is critical to understand the effect of Medicaid expansion. This review aims to better prepare investigators and their audiences to fully understand the implications of this important health policy initiative.

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Evaluation of Cancer Care After Medicaid Expansion Under the Affordable Care Act

Cited by 4 publications

References 4 publications

Stage at diagnosis and survival among adolescents and young adults with lymphomas following the Affordable Care Act implementation in California

Stage at diagnosis and survival among adolescents and young adults with lymphomas following the Affordable Care Act implementation in California

Pathways to ovarian cancer diagnosis: a qualitative study

Understanding the Implications of Medicaid Expansion for Cancer Care in the US

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