Early- and Late-Stage Cancer Diagnosis Under 3 Years of Medicaid Expansion.
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ABSTRACT: Introduction
Health insurance expansions may increase early detection of cancer and reduce late-stage cancer incidence. The study assesses the effects of the Affordable Care Act Medicaid expansions on rates of early- and late-stage cancer diagnosis up to 3 years after implementation.Methods
Population-based quasi-experimental analysis of nonelderly adults was conducted in 732 counties from the 2010-2016 Surveillance, Epidemiology, and End Results Program cancer registry data. Multivariate event study regressions were estimated to compare annual changes in county-level rates of cancer diagnoses in states that expanded Medicaid with those that did not. Data analysis was performed from May to October 2019.Results
Medicaid expansion was associated with an increase in early-stage cancer diagnoses of 21.3 per 100,000 population (95% CI=2.9, 35.2) or 9.14% of population in its first year; estimates for Years 2 and 3 were also positive but smaller and not statistically significant. There was a marginally significant reduction in late-stage diagnoses of 8.7 per 100,000 population (95% CI= -25.0, 3.4) or 5.7% of population relative to baseline, 3 years after Medicaid expansion. There was no detectable effect of expansion on total diagnoses.Conclusions
Medicaid expansions increased early-stage cancer diagnosis in the first year of expansion, but effects dissipated in subsequent years, suggesting a response to pent-up patient demand for screening and diagnostic services immediately after expansion. There was also suggestive evidence of reductions in late-stage diagnosis in the third year of Medicaid expansion, highlighting the potential role of public health insurance in improving cancer outcomes among nonelderly adults.
SUBMITTER: Lin L
PROVIDER: S-EPMC7750288 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:ImportanceThe expansion of Medicaid sought to fill gaps in insurance coverage among low-income Americans. Although coverage has improved, little is known about the relationship between Medicaid expansion and breast cancer stage at diagnosis.ObjectiveTo review the association of Medicaid expansion with breast cancer stage at diagnosis and the disparities associated with insurance status, age, and race/ethnicity.Design, setting, and participantsThis cohort study used data from the National Cancer Database to characterize the relationship between breast cancer stage and race/ethnicity, age, and insurance status. Data from 2007 to 2016 were obtained, and breast cancer stage trends were assessed. Additionally, preexpansion years (2012-2013) were compared with postexpansion years (2015-2016) to assess Medicaid expansion in 2014. Data were analyzed from August 12, 2019, to January 19, 2020. The cohort included a total of 1 796 902 patients with primary breast cancer who had private insurance, Medicare, or Medicaid or were uninsured across 45 states.Main outcomes and measuresPercent change of uninsured patients with breast cancer and stage at diagnosis, stratified by insurance status, race/ethnicity, age, and state.ResultsThis study included a total of 1 796 902 women. Between 2012 and 2016, 71 235 (4.0%) were uninsured or had Medicaid. Among all races/ethnicities, in expansion states, there was a reduction in uninsured patients from 22.6% (4771 of 21 127) to 13.5% (2999 of 22 150) (P < .001), and in nonexpansion states, there was a reduction from 36.5% (5431 of 14 870) to 35.6% (4663 of 13 088) (P = .12). Across all races, there was a reduction in advanced-stage disease from 21.8% (4603 of 21 127) to 19.3% (4280 of 22 150) (P < .001) in expansion states compared with 24.2% (3604 of 14 870) to 23.5% (3072 of 13 088) (P = .14) in nonexpansion states. In African American patients, incidence of advanced disease decreased from 24.6% (1017 of 4136) to 21.6% (920 of 4259) (P < .001) in expansion states and remained at approximately 27% (27.4% [1220 of 4453] to 27.5% [1078 of 3924]; P = .94) in nonexpansion states. Further analysis suggested that the improvement was associated with a reduction in stage 3 diagnoses.Conclusions and relevanceIn this cohort study, expansion of Medicaid was associated with a reduced number of uninsured patients and a reduced incidence of advanced-stage breast cancer. African American patients and patients younger than 50 years experienced particular benefit. These data suggest that increasing access to health care resources may alter the distribution of breast cancer stage at diagnosis.
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Project description:ContextPrior studies demonstrate that Medicaid expansion has been associated with earlier-stage breast cancer diagnosis among women with low income, likely through increased access to cancer screening services. However, how this policy change has impacted geospatial disparities in breast cancer stage at diagnosis is unclear.ObjectiveTo examine whether there were reductions in geospatial disparities in advanced stage breast cancer at diagnosis in Ohio after Medicaid expansion.DesignThe study included 33 537 women aged 40 to 64 years diagnosed with invasive breast cancer from the Ohio Cancer Incidence Surveillance System between 2010 and 2017. The space-time scan statistic was used to detect clusters of advanced stage at diagnosis before and after Medicaid expansion. Block group variables from the Census were used to describe the contextual characteristics of detected clusters.ResultsThe percentage of local stage diagnosis among women with breast cancer increased from 60.2% in the pre-expansion period (2010-2013) to 62.6% in the post-expansion period (2014-2017), while the uninsured rate among those women decreased from 13.7% to 7.5% during the same period. Two statistically significant ( P < .05) and 6 nonsignificant spatial clusters ( P > .05) of advanced stage breast cancer cases were found in the pre-expansion period, while none were found in the post-expansion period. These clusters were in the 4 largest metropolitan areas in Ohio, and individuals inside the clusters were more likely to be disadvantaged along numerous socioeconomic factors.ConclusionsMedicaid expansion has played an important role in reducing geospatial disparities in breast cancer stage at diagnosis, likely through the reduction of advanced stage disease among women living in socioeconomically disadvantaged communities.
| S-EPMC9308621 | biostudies-literature
Project description:BackgroundDisrupted and delayed Medicaid coverage has been consistently associated with lower rates of cancer screening and early-stage cancer diagnosis compared with continuous coverage. However, the relationships between Medicaid coverage timing, breast cancer treatment delays, and survival are less clear.MethodsUsing the linked Missouri Cancer Registry-Medicaid claims data, we identified 4583 women diagnosed with breast cancer between 2007 and 2016. We used logistic regression to estimate odds ratios (ORs) of late-stage diagnosis and treatment delays for prediagnosis (>30 days, >90 days, and >1 year before diagnosis) vs peridiagnosis enrollment. Cox proportional hazards models were used to estimate the hazard ratio (HR) of breast cancer-specific mortality for pre- vs postdiagnosis enrollment.ResultsPatients enrolled in Medicaid more than 30 days before diagnosis were less likely to be diagnosed at a late stage compared with those enrolled in Medicaid peridiagnosis (OR = 0.69, 95% confidence interval [CI] = 0.60 to 0.79). This result persisted using enrollment 90-day (OR = 0.64, 95% CI = 0.56 to 0.74) and 1-year thresholds (OR = 0.55, 95% CI = 0.47 to 0.65). We did not observe a difference in the likelihood of treatment delays between the 2 groups. After adjustment for sociodemographic factors, there was no statistically significant difference in the risk of breast cancer mortality for patients enrolled more than 30 days prediagnosis relative to patients enrolled peridiagnosis (HR = 0.98, 95% CI = 0.83 to 1.14), but a lower risk was observed for patients enrolled prediagnosis when using 90 days (HR = 0.85, 95% CI = 0.72 to 0.999) or 1 year (HR = 0.79, 95% CI = 0.66 to 0.96) as the threshold.ConclusionsWomen with breast cancer who enroll in Medicaid earlier may benefit from earlier diagnoses, but only longer-term enrollment may have survival benefits.
| S-EPMC9113434 | biostudies-literature
Project description:ImportanceMedicaid expansion under the Patient Protection and Affordable Care Act is associated with gains in health insurance coverage, earlier stage diagnosis, and improved survival among patients with cancer.ObjectiveTo examine the association of Medicaid expansion with changes in early mortality among adults undergoing surgical resection of non-small cell lung cancer (NSCLC), a setting in which access to care is a major determinant of survival.Design, setting, and participantsThis cohort study used the National Cancer Database to identify 14 984 adults 45 to 64 years of age who underwent surgical resection of NSCLC between 2008 and 2019. Analysis was conducted between March 28, 2021, and September 1, 2023.ExposureState of residence Medicaid expansion status.Main outcomes and measuresDescriptive statistics were used to compare study population characteristics by Medicaid expansion status of patients' state of residence. Difference-in-differences analyses were used to evaluate the association between Medicaid expansion and postoperative mortality before implementation of the ACA (2008-2013) vs after (2014-2019).ResultsAmong 14 984 adults included, the mean (SD) age was 56.3 (5.1) years, 54.6% were women, and 62.1% lived in Medicaid expansion states. Both 30-day (from 0.97% to 0.26%) and 90-day (from 2.63% to 1.32%) postoperative mortality decreased from before the ACA to after among patients residing in Medicaid expansion states (both P < .001) but not in nonexpansion states (30-day mortality before the ACA, 0.75% vs after the ACA, 0.68%; P = .74; and 90-day mortality before the ACA, 2.43% vs after the ACA, 2.20%; P = .57), leading to a difference-in-differences of -0.64 percentage points (95% CI, -1.19 to -0.08; P = .03) for 30-day mortality and -1.08 percentage points (95% CI, -2.08 to -0.08; P = .03) for 90-day mortality. The difference-in-differences for in-hospital mortality was not significant (P = .34) between expansion states (1.41% before the ACA to 0.77% after the ACA; 0.63 percentage point decrease; P = .004) and nonexpansion states (1.49% before the ACA to 1.20% after the ACA; 0.30 percentage point decrease; P = .29).Conclusions and relevanceIn this cohort study of patients with NSCLC, Medicaid expansion was associated with declines in 30- and 90-day postoperative mortality following hospital discharge. These findings suggest that Medicaid expansion may be an effective strategy for improving access to care and cancer outcomes in this population.
| S-EPMC10787311 | biostudies-literature
Project description: Not available
| S-EPMC7895308 | biostudies-literature
Project description:IntroductionWe sought to assess the impact of Affordable Care Act Dependent Care Expansion (ACA-DCE), which allowed dependent coverage for adults aged 19-25, and Medicaid expansion on outcomes for men with testicular cancer.MethodsUsing a US-based cancer registry, we performed adjusted difference-in-difference (DID) analyses comparing outcomes between men aged 19-25 (n = 8,026) and 26-64 (n = 33,303) pre- (2007-2009) and post-ACA-DCE (2011-2016) and between men in states that expanded Medicaid (n = 2,296) to men in those that did not (n = 2,265)pre- (2011-2013) and post-Medicaid expansion (2015-2016).ResultsIn ACA-DCE analysis, rates of uninsurance decreased (DID -5.64, 95% confidence interval [CI] -7.23 to -4.04%, p<0.001) among patients aged 19-25 relative to older patients aged 26-64. There was no significant DID in advanced stage at diagnosis (stage≥II; p = 0.6) or orchiectomy more than 14 days after diagnosis (p = 0.6). For patients who received chemotherapy or radiotherapy as their first course of treatment, treatment greater than 60 days after diagnosis decreased (DID -4.84%, 95% CI -8.22 to -1.45%, p = 0.005) among patients aged 19-25 relative to patients aged 26-64. In Medicaid expansion states, rates of uninsurance decreased (DID -4.20%, 95% CI -7.67 to -0.73%, p = 0.018) while patients receiving chemotherapy or radiotherapy greater than 60 days after diagnosis decreased (DID -8.76, 95% CI -17.13 to -0.38%, p = 0.040) compared to rates in non-expansion states. No significant DIDs were seen for stage (p = 0.8) or time to orchiectomy (p = 0.1).ConclusionsMen with testicular cancer had lower uninsurance rates and decreased time to delivery of chemotherapy or radiotherapy following ACA-DCE and Medicaid expansions. Time to orchiectomy and stage at diagnosis did not change following either insurance expansion.
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Project description:ImportanceThere are stark disparities in cervical cancer burden in the United States, notably by race and ethnicity and geography. Late-stage diagnosis is an indicator of inadequate access to and utilization of screening.ObjectiveTo identify geospatial clusters of late-stage cervical cancer at time of diagnosis in Texas.Design, setting, and participantsThis population-based cross-sectional study used incident cervical cancer data from the Texas Cancer Registry from 2014 to 2018 of female patients aged 18 years or older. Late-stage cervical cancer cases were geocoded at the census tract level (n = 5265) using their residential coordinates (latitude and longitude) at the time of diagnosis. Statistical analysis was performed from April to September 2023.ExposuresCensus tract of residence at diagnosis.Main outcome and measuresLate-stage cervical cancer diagnosis (ie, cases classified by the National Cancer Institute Surveillance, Epidemiology and End Results summary stages 2 to 4 [regional spread] or 7 [distant metastasis]). A Poisson probability-based model of the SaTScan purely spatial scan statistics was applied at the census tract-level to identify geographic clusters of higher (hot spots) or lower (cold spots) proportions than expected of late-stage cervical cancer diagnosis and adjusted for age.ResultsAmong a total of 6484 female patients with incident cervical cancer cases (mean [SD] age, 48.7 [14.7] years), 2300 (35.5%) were Hispanic, 798 (12.3%) were non-Hispanic Black, 3090 (47.6%) were non-Hispanic White, and 296 (4.6%) were other race or ethnicity. Of the 6484 patients, 2892 with late-stage diagnosis (mean [SD] age, 51.8 [14.4] years were analyzed. Among patients with late-stage diagnosis, 1069 (37.0%) were Hispanic, 417 (14.4%) were non-Hispanic Black, 1307 (45.2%) were non-Hispanic White, and 99 (3.4%) were other race or ethnicity. SaTScan spatial analysis identified 7 statistically significant clusters of late-stage cervical cancer diagnosis in Texas, of which 4 were hot spots and 3 were cold spots. Hot spots included 1128 census tracts, predominantly in the South Texas Plains, Gulf Coast, and Prairies and Lakes (North Texas) regions. Of the 2892 patients with late-stage cervical cancer, 880 (30.4%) were observed within hot spots. Census tract-level comparison of characteristics of clusters suggested that hot spots differed significantly from cold spots and the rest of Texas by proportions of racial and ethnic groups, non-US born persons, and socioeconomic status.Conclusions and relevanceIn this cross-sectional study examining geospatial clusters of late-stage cervical cancer diagnosis, place-based disparities were found in late-stage cervical cancer diagnosis in Texas. These findings suggest that these communities may benefit from aggressive cervical cancer interventions.
| S-EPMC10644213 | biostudies-literature
Project description:ObjectivePrevious research found an association between California's Medicaid dental coverage and oral cancer detection. However, this relationship has yet to be explored in other states or by subgroup populations.Study designIn addition to controlling for sociodemographic and tumor characteristics, this study implemented a traditional difference-in-differences design to compare distant-stage diagnosis trends in states restoring Medicaid dental benefits (California [CA] and Illinois [IL]) with trends in states with constant Medicaid dental benefits.SettingThis retrospective, observational study analyzed oral cavity and pharynx cancer case data from The Surveillance, Epidemiology, and End Results program (2004-2017).MethodsThe outcome was a binary variable indicating whether a patient was diagnosed at a distant stage. Subgroup analyses were conducted by state, race/ethnic group, sex, age, and county-level household income.ResultsThe sample included 109,997 adults diagnosed with cancer of the oral cavity and pharynx. Restoring Medicaid dental benefits was associated with a statistically significant 2.7%-point decline in the probability of a distant-stage oral cancer diagnosis. This estimate represented a 14% relative change from baseline rates. Results were consistent for CA and IL and by county-level median income. Estimates were significantly larger for adults under age 65, males, and adults identifying as Hispanic; non-Hispanic Black; American Indian; or Asian American or Pacific Islander.ConclusionRestoring Medicaid dental coverage improved early detection in both CA and IL, with the greatest reductions in distant-stage diagnoses occurring in younger adults, males, and minoritized racial/ethnic groups. Future research should investigate whether earlier detection reduces oral cancer mortality disparities.
| S-EPMC10790188 | biostudies-literature
Project description:BackgroundYoung adults (YAs) experience higher uninsurance rates and more advanced stage at cancer diagnosis than older counterparts. We examined the association of the Affordable Care Act Medicaid expansion with insurance coverage and stage at diagnosis among YAs newly diagnosed with cancer.MethodsUsing the National Cancer Database, we identified 309 413 YAs aged 18-39 years who received a first cancer diagnosis in 2011-2016. Outcomes included percentages of YAs without health insurance at diagnosis, with stage I (early-stage) diagnoses, and with stage IV (advanced-stage) diagnoses. We conducted difference-in-difference (DD) analyses to examine outcomes before and after states implemented Medicaid expansion compared with nonexpansion states. All statistical tests were 2-sided.ResultsThe percentage of uninsured YAs decreased more in expansion than nonexpansion states (adjusted DD = -1.0 percentage points [ppt], 95% confidence interval [CI] = -1.4 to -0.7 ppt, P < .001). The overall percentage of stage I diagnoses increased (adjusted DD = 1.4 ppt, 95% CI = 0.6 to 2.2 ppt, P < .001) in expansion compared with nonexpansion states, with greater improvement among YAs in rural areas (adjusted DD = 7.2 ppt, 95% CI = 0.2 to 14.3 ppt, P = .045) than metropolitan areas (adjusted DD = 1.3 ppt, 95% CI = 0.4 to 2.2 ppt, P = .004) and among non-Hispanic Black patients (adjusted DD = 2.2 ppt, 95% CI = -0.03 to 4.4 ppt, P = .05) than non-Hispanic White patients (adjusted DD = 1.4 ppt, 95% CI = 0.4 to 2.3 ppt, P = .008). Despite the non-statistically significant change in stage IV diagnoses overall, the percentage declined more (adjusted DD = -1.2 ppt, 95% CI = -2.2 to -0.2 ppt, P = .02) among melanoma patients in expansion relative to nonexpansion states.ConclusionsWe provide the first evidence, to our knowledge, on the association of Medicaid expansion with shifts to early-stage cancer at diagnosis and a narrowing of rural-urban and Black-White disparities in YA cancer patients.
| S-EPMC9989840 | biostudies-literature
Project description:ImportanceHealth 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.ObjectiveTo 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.Design, setting, and participantsThis case-control study included adults aged 18 to 64 years with a new primary diagnosis of kidney, bladder, or prostate cancer, selected from the National Cancer Database from January 1, 2011, to December 31, 2016. Patients in states that expanded Medicaid were the case group, and patients in nonexpansion states were the control group. Data were analyzed from January 2020 to March 2021.ExposuresState Medicaid expansion status.Main outcomes and measuresInsurance status, stage at diagnosis, and receipt of cancer and stage-specific treatments. Cases and controls were compared with difference-in-difference analyses.ResultsAmong a total of 340 552 patients with newly diagnosed genitourinary cancers, 94 033 (27.6%) had kidney cancer, 25 770 (7.6%) had bladder cancer, and 220 749 (64.8%) had prostate cancer. Medicaid expansion was associated with a net decrease in uninsured rate of 1.1 (95% CI, -1.4 to -0.8) percentage points across all incomes and a net decrease in the low-income population of 4.4 (95% CI, -5.7 to -3.0) percentage points compared with nonexpansion states. Expansion was also associated with a significant shift toward early-stage diagnosis in kidney cancer across all income levels (difference-in-difference, 1.4 [95% CI, 0.1 to 2.6] percentage points) and among individuals with low income (difference-in-difference, 4.6 [95% CI, 0.3 to 9.0] percentage points) and in prostate cancer among individuals with low income (difference-in-difference, 3.0 [95% CI, 0.3 to 5.7] percentage points). Additionally, there was a net increase associated with expansion compared with nonexpansion in receipt of active surveillance for low-risk prostate cancer of 4.1 (95% CI, 2.9 to 5.3) percentage points across incomes and 4.5 (95% CI, 0 to 9.0) percentage points among patients in low-income areas.Conclusions and relevanceThese findings suggest that Medicaid expansion was associated with decreases in uninsured status, increases in the proportion of kidney and prostate cancer diagnosed in an early stage, and higher rates of active surveillance in the appropriate, low-risk prostate cancer population. Associations were concentrated in population residing in low-income areas and reinforce the importance of improving access to care to all patients with cancer.
| S-EPMC8134994 | biostudies-literature