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

Moss, Haley A.; Wu, Jy S.; Kaplan, Samantha; Zafar, S. Yousuf

doi:10.1093/jnci/djaa043

Cited by 63 publications

(67 citation statements)

References 67 publications

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“…With the passing of the ACA, there has been a decrease in the rate of uninsured patients 32,33 as well as fewer patients with advanced cancer stages at diagnosis 34,35 in the states that have expanded Medicaid. This study adds to the ongoing body of research and the public health push for Missouri and other states to consider Medicaid expansion as a protection for their most vulnerable populations 36,37 . Furthermore, with research showing the effectiveness of patient‐focused breast cancer education programs 38,39 and the cost‐effectiveness of funding breast cancer screening programs, 40 furthering efforts to fund screening and education programs can further decrease disparities.…”

Section: Discussionmentioning

confidence: 90%

Relationship between insurance status and outcomes for patients with breast cancer in Missouri

Berrian

Liu

Lian

et al. 2020

Cancer

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Background The cancer stage at diagnosis, treatment delays, and breast cancer mortality vary with insurance status. Methods Using the Missouri Cancer Registry, this analysis included 31,485 women diagnosed with invasive breast cancer from January 1, 2007, to December 31, 2015. Odds ratios (ORs) of a late‐stage (stage III or IV) diagnosis and a treatment delay (>60 days after the diagnosis) were calculated with logistic regression. The hazard ratio (HR) of breast cancer mortality was calculated with Cox proportional hazards regression. Mediation analysis was used to quantify the individual contributions of each covariate to mortality. Results The OR of a late‐stage diagnosis was higher for patients with Medicaid (OR, 1.72; 95% confidence interval [CI], 1.56‐1.91) or no insurance (OR, 2.30; 95% CI, 1.91‐2.78) in comparison with privately insured patients. Medicare (OR, 1.21; 95% CI, 1.10‐1.37), Medicaid (OR, 1.60; 95% CI, 1.37‐1.85), and uninsured patients (OR, 1.58; 95% CI, 1.18‐2.12) had higher odds of a treatment delay. The HR of breast cancer–specific mortality was significantly increased in the groups with public insurance or no insurance and decreased after sequential adjustments for sociodemographic factors (HR, 2.39; 95% CI, 1.96‐2.91), tumor characteristics (HR, 1.28; 95% CI, 1.05‐1.56), and treatment (HR, 1.23; 95% CI, 1.01‐1.50). Late‐stage diagnoses accounted for 72.5% of breast cancer mortality in the uninsured. Conclusions Compared with the privately insured, women with public or no insurance had a higher risk for advanced breast cancer, a >60‐day treatment delay, and death from breast cancer. Particularly for the uninsured, Medicaid expansion and increased funding for education and screening programs could decrease breast cancer disparities.

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Section: Discussionmentioning

confidence: 90%

Relationship between insurance status and outcomes for patients with breast cancer in Missouri

Berrian

Liu

Lian

et al. 2020

Cancer

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“…This trend is consistent with other studies that have shown that Medicaid expansion was associated with reduced socioeconomic disparity in insurance rates. 20 , 21 , 22 Importantly, our findings suggest that the downstream stage and treatment outcomes were also magnified in the low-income population. The fact that changes in the low-income population are associated with trends toward earlier diagnosis and receipt of indicated treatment suggests that expansion of insurance may be a valid mechanism to help reduce cancer disparity.…”

Section: Discussionmentioning

confidence: 63%

“…19 Previous research on the associations of Medicaid expansion with cancer care has focused on the association of expansion with the decreasing proportion of uninsured individuals rather than other aspects of cancer care, such as diagnosis and treatment. [20][21][22][23] Only a handful of studies have studied further downstream metrics, and they have identified small shifts to earlier stage disease in a few nongenitourinary cancers 21,22,24 and an increase in utilization of surgery for all cancers in aggregate. [25][26][27] However, these studies have generally been limited to only a year of postimplementation data, and the association of Medicaid expansion with alleviating racial/ethnic or socioeconomic disparity has been inconsistent between different subgroups and cancer types.…”

Section: Introductionmentioning

confidence: 99%

Associations of Medicaid Expansion With Insurance Coverage, Stage at Diagnosis, and Treatment Among Patients With Genitourinary Malignant Neoplasms

et al. 2021

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IMPORTANCE Health insurance coverage is associated with improved outcomes in patients with cancer. However, it is unknown whether Medicaid expansion through the Patient Protection and Affordable Care Act (ACA) was associated with improvements in the diagnosis and treatment of patients with genitourinary cancer. OBJECTIVE To assess the association of Medicaid expansion with health insurance status, stage at diagnosis, and receipt of treatment among nonelderly patients with newly diagnosed kidney, bladder, or prostate cancer.

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“…Levels and trends of mortality disparities could also reflect effects after earlier adoption of universal health coverage in Massachusetts compared with Pennsylvania. Current evidence suggests that the Medicaid expansion provision of the ACA succeeded in increasing insurance coverage as well as access to ambulatory and surgical cancer care, and possibly led to lower stage at presentation among low‐income populations, 12,39,40 but had less effect on the use of cancer prevention services and race/ethnicity disparities in access 39,41,42 . Massachusetts is a wealthier and more densely populated state than Pennsylvania, which also could have resulted in smaller absolute disparities based on race/ethnicity and nSEP.…”

Section: Discussionmentioning

confidence: 99%

Trends in mortality among Black and White men with prostate cancer in Massachusetts and Pennsylvania: Race and neighborhood socioeconomic position

Iyer

Gomez

Chen

et al. 2021

Cancer

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Background Reducing disparities in men with prostate cancer (PCa) that may be caused by racial and socioeconomic differences is a major public health priority. Few reports have studied whether these disparities have changed over time. Methods Men diagnosed with PCa from January 1, 2000 to December 31, 2015 were identified from the Massachusetts and Pennsylvania cancer registries. All‐cause mortality and PCa and cardiovascular cause‐specific mortality were assessed. To estimate neighborhood socioeconomic position (nSEP), a summary score was generated using census tract‐level measures of income, wealth, educational attainment, and racial and income segregation. Participants were grouped by diagnosis year (2000‐2003, 2004‐2007, 2008‐2011, or 2012‐2015), and changing trends in the mortality rate ratio by race and nSEP were estimated using covariate‐adjusted Cox models with follow‐up for up to 10 years, until death, or until censoring on January 1, 2018. Results There were 193,883 patients with PCa and 43,661 deaths over 1,404,131 person‐years of follow‐up. The Black‐White adjusted hazard ratio (aHR) from 2000 to 2003 through 2012 to 2015 was stable for all‐cause mortality (aHR, 1.14 to 0.97; P for heterogeneity = .42), decreased for PCa‐specific mortality (aHR, 1.38 to 0.93; P for heterogeneity = .005), and increased for cardiovascular mortality (aHR, 1.09 to 1.28; P for heterogeneity = .034). The aHR comparing those in the lowest versus the highest nSEP quintile increased significantly for all‐cause mortality (aHR, 1.54 to 1.79; P for heterogeneity = .008), but not for PCa‐specific mortality (aHR, 1.60 to 1.72; P for heterogeneity = .40) or cardiovascular mortality (aHR, 1.72 to 1.89; P for heterogeneity = .085). conclusions Although Black‐White disparities in prostate mortality declined in Massachusetts and Pennsylvania over the study period, nSEP mortality disparity trends were stagnant or increased, warranting further attention. Lay Summary Few reports have examined whether racial and socioeconomic disparities in prostate cancer mortality have widened or narrowed in recent years. Using data from 2 state registries (Massachusetts and Pennsylvania) with differing intensities of government‐mandated health insurance, trends in racial and neighborhood socioeconomic disparities were studied among Black and White men diagnosed from 2000 to 2015. Overall, trends in racial disparities were stagnant for all‐cause mortality, shrank for prostate mortality, and widened for cardiovascular mortality. Disparities associated with neighborhood socioeconomic status either were stagnant or widened across all mortality end points. In general, disparities were more pronounced in Pennsylvania than in Massachusetts.

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

Cited by 63 publications

References 67 publications

Relationship between insurance status and outcomes for patients with breast cancer in Missouri

Relationship between insurance status and outcomes for patients with breast cancer in Missouri

Associations of Medicaid Expansion With Insurance Coverage, Stage at Diagnosis, and Treatment Among Patients With Genitourinary Malignant Neoplasms

Trends in mortality among Black and White men with prostate cancer in Massachusetts and Pennsylvania: Race and neighborhood socioeconomic position

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