Search

Female breast cancer is a common cancer in young adults, an age group with the highest uninsured rate. Among 51 675 young adult women (ages 18-39 years) diagnosed with breast cancer between 2011 and 2018 in the National Cancer Database, we estimated changes in guideline-concordant treatment receipt, treatment timeliness, and survival associated with the Affordable Care Act Medicaid expansion. Of young adults with stage I-III estrogen receptor-positive or progesterone receptor-positive breast cancer, Medicaid expansion was associated with a net increase of 2.42 percentage points (95% confidence interval [CI] = 0.56 to 4.28 percentage points) in the percentage receiving endocrine therapy. Among all young adults with stage I-III breast cancer, Medicaid expansion was associated with a net reduction of 1.65 percentage points (95% CI = 0.08 to 3.22 percentage points) in treatment delays defined as treatment initiation of at least 60 days after diagnosis and a net increase of 1.00 percentage points (95% CI = 0.21 to 1.79 percentage points) in 2-year overall survival. Our study provides evidence of benefit in cancer care and outcomes from Medicaid expansion among the young adult population., (© The Author(s) 2023. Published by Oxford University Press.)

Background: Medicaid expansion is associated with improved survival following cancer diagnosis. However, little research has assessed how changes in cancer stage may mediate improved cancer mortality or how expansion may have decreased population-level cancer mortality rates., Methods: Nationwide state-level cancer data from 2001 to 2019 for individuals ages 20-64 years were obtained from the combined Surveillance, Epidemiology, and End Results National Program of Cancer Registries (incidence) and the National Center for Health Statistics (mortality) databases. We estimated changes in distant stage cancer incidence and cancer mortality rates from pre- to post-2014 in expansion vs nonexpansion states using generalized estimating equations with robust standard errors. Mediation analyses were used to assess whether distant stage cancer incidence mediated changes in cancer mortality., Results: There were 17 370 state-level observations. For all cancers combined, there were Medicaid expansion-associated decreases in distant stage cancer incidence (adjusted odds ratio = 0.967, 95% confidence interval  = 0.943 to 0.992; P = .01) and cancer mortality (adjusted odds ratio = 0.965, 95% confidence interval = 0.936 to 0.995; P = .022). This translates to 2591 averted distant stage cancer diagnoses and 1616 averted cancer deaths in the Medicaid expansion states. Distant stage cancer incidence mediated 58.4% of expansion-associated changes in cancer mortality overall (P = .008). By cancer site subgroups, there were expansion-associated decreases in breast, cervix, and liver cancer mortality., Conclusions: Medicaid expansion was associated with decreased distant stage cancer incidence and cancer mortality. Approximately 60% of the expansion-associated changes in cancer mortality overall were mediated by distant stage diagnoses., (© The Author(s) 2023. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Purpose: Medicaid expansion through the Affordable Care Act (ACA) has been shown to improve insurance coverage and early diagnosis of cancer in young adults (YAs); whether these improvements translate to survival benefits remains unknown. We examined the association between Medicaid expansion under the ACA and 2-year overall survival among YAs with cancer., Methods: Using the National Cancer Database, we identified 345,413 YAs (age 18-39 years) diagnosed with cancer in 2010-2017. We applied the difference-in-differences (DD) method to estimate changes in 2-year overall survival after versus before Medicaid expansion in expansion versus nonexpansion states., Results: Among all YAs, 2-year overall survival increased more in expansion states (90.39% pre-expansion to 91.85% postexpansion) than in nonexpansion states (88.98% pre-expansion to 90.07% postexpansion), resulting in a net increase of 0.55 percentage points (ppt; 95% CI, 0.13 to 0.96). The expansion-associated survival benefit was concentrated in patients with female breast cancer (DD, 1.20 ppt; 95%CI, 0.27 to 2.12) when stratifying by cancer type and in patients with stage IV disease (DD, 2.56; 95%CI, 0.36 to 4.77) when stratifying by stage. In addition, greater survival benefit associated with Medicaid expansion was observed among racial and ethnic minoritized groups (DD, 1.01 ppt; 95% CI, 0.14 to 1.87) as compared with non-Hispanic White peers (DD, 0.41 ppt; 95% CI, -0.06 to 0.87) and among patients with a Charlson comorbidity score of ≥ 2 (DD, 6.48 ppt; 95% CI, 0.81 to 12.16) than those with a comorbidity score of 0 (DD, 0.44 ppt; 95% CI, 0.005 to 0.87)., Conclusion: Medicaid expansion under the ACA was associated with an improvement in overall survival among YAs with cancer, with survival benefits most pronounced among patients of under-represented race and ethnicity and patients with high-risk diseases.

Purpose: To examine the association between historic state Medicaid income eligibility limits and long-term survival among patients with cancer., Methods: 1,449,144 adults age 18-64 years newly diagnosed with 19 common cancers between 2010 and 2013 were identified from the National Cancer Database. States' Medicaid income eligibility limits were categorized as ≤ 50%, 51%-137%, and ≥ 138% of federal poverty level (FPL). Survival time was measured from diagnosis date through December 31, 2017, for up to an 8-year follow-up. Multivariable Cox proportional hazards models with age as time scale were used to assess associations of eligibility limits and stage-specific survival, adjusting for the effects of sex, metropolitan statistical area, comorbidities, year of diagnosis, facility type and volume, and state., Results: Among patients with newly diagnosed cancer age 18-64 years, patients living in states with lower Medicaid income eligibility limits had worse survival for most cancers in both early and late stages, compared with those living in states with Medicaid income eligibility limits ≥ 138% FPL. A dose-response relationship was observed for most cancers with lower income limits associated with worse survival (13 of 17 cancers evaluated for early-stage cancers, and 11 of 17 cancers evaluated for late-stage cancers, and leukemia and brain tumors with P -trend < .05)., Conclusion: Lower Medicaid income eligibility limits were associated with worse long-term survival within stage; increasing Medicaid income eligibility may improve survival after cancer diagnosis., Competing Interests: Jingxuan ZhaoResearch Funding: AstraZeneca Xuesong HanResearch Funding: AstraZeneca K. Robin YabroffConsulting or Advisory Role: Flatiron Health (Inst)No other potential conflicts of interest were reported.

Background: Young 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., Methods: Using 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., Results: The 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., Conclusions: We 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., (© The Author(s) 2021. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

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., Design, Setting, and Participants: This 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., Exposures: State Medicaid expansion status., Main Outcomes and Measures: Insurance status, stage at diagnosis, and receipt of cancer and stage-specific treatments. Cases and controls were compared with difference-in-difference analyses., Results: Among 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 Relevance: These 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.

Importance: Medicaid expansions as part of the Patient Protection and Affordable Care Act (ACA) are associated with decreases in the percentage of uninsured patients who have received a new diagnosis of cancer. Little is known about the association of Medicaid expansions with stage at diagnosis and time to treatment initiation (TTI) for patients with head and neck squamous cell carcinoma (HNSCC)., Objective: To determine the association of Medicaid expansions as part of the ACA with stage at diagnosis and TTI for patients with HNSCC., Design, Setting, and Participants: A retrospective cohort study was conducted at Commission on Cancer-accredited facilities among 90 789 patients identified from the National Cancer Database aged 18 to 64 years with HNSCC that was diagnosed during the period from January 1, 2010, to December 31, 2016. Statistical analysis was conducted from February 18 to November 8, 2019., Main Outcomes and Measures: Outcome measures included health insurance coverage, stage at diagnosis, and TTI. Absolute percentage change in health insurance coverage, crude and adjusted difference in differences (DD) in absolute percentage change in coverage, stage at diagnosis, and TTI before (2010-2013) and after (2014-2016) ACA implementation were calculated for Medicaid expansion and nonexpansion states., Results: Of the 90 789 nonelderly adults with newly diagnosed HNSCC (mean [SD] age, 54.7 [7.0] years), 70 907 (78.1%) were men, 72 911 (80.3%) were non-Hispanic white, 52 142 (57.4%) were between 55 and 64 years of age, and 54 940 (60.5%) resided in states with an ACA Medicaid expansion. Compared with nonexpansion states, the percentage of patients with HNSCC with Medicaid increased more in expansion states after the implementation of the ACA (adjusted DD, 4.6 percentage points [95% CI, 3.7-5.4 percentage points]). The percentage of patients with localized disease (American Joint Committee on Cancer stage I-II) at diagnosis increased in expansion states compared with nonexpansion states for the overall cohort (adjusted DD, 2.3 percentage points [95% CI, 1.1-3.5 percentage points]) and for the subset of patients with nonoropharyngeal HNSCC (adjusted DD, 3.4 percentage points [95% CI, 1.5-5.2 percentage points]). The mean TTI did not differ between expansion and nonexpansion states for the cohort (adjusted DD, -12.7 percentage points [95% CI, -27.4 to 4.2 percentage points]) but improved for patients with nonoropharyngeal HNSCC (adjusted DD, -26.5 percentage points [95% CI, -49.6 to -3.4 percentage points])., Conclusions and Relevance: This study suggests that Medicaid expansions were associated with a greater increase in the percentage of patients with HNSCC with Medicaid coverage, an increase in the percentage of patients with localized disease at diagnosis for the overall cohort of patients with HNSCC, and improved TTI for patients with nonoropharyngeal HNSCC.

Introduction: Medicaid expansions following the Affordable Care Act have improved insurance coverage in low-income adults, but little is known about its impact on cancer screening. This study examined associations between Medicaid expansion timing and colorectal cancer (CRC) and breast cancer (BC) screening., Methods: Up-to-date and past 2-year CRC (n=95,400) and BC (women, n=43,279) screening prevalence were computed among low-income respondents aged 50-64 years in 2012, 2014, and 2016 Behavioral Risk Factor Surveillance System data. Respondents were grouped according to Medicaid expansion timing as: very early ([VE] six states expanding March 1, 2010-April 14, 2011), early (21 states expanding January 1, 2014-August 15, 2014), late (five states expanding January 1, 2015-July 1, 2016), and non-expansion states (19 states). Absolute adjusted difference-in-differences (aDDs) were computed in 2018-2019 (ref, non-expansion states)., Results: Between 2012 and 2016, absolute up-to-date CRC screening increased by 8.8%, 2.9%, 2.4%, and 3.8% among low-income adults in VE, early, late, and non-expansion states, respectively. Past 2-year CRC screening increased by 8.0% in VE and 2.8% in non-expansion states, with an aDD of 4.9% (p=0.041). In 2012-2016, up-to-date BC screening increased by 5.1%, 4.9%, and 3.7% among low-income women in VE, early, and non-expansion states, respectively, but aDDs were not statistically significant., Conclusions: Prevalence of CRC and BC screening among low-income adults rose in Medicaid expansion states, though increases were significantly higher than those in non-expansion states only for recent CRC screening in VE expansion states. Large-scale improvements in cancer screening may take several years following expansion in access to care., (Copyright © 2019 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Cancer survivors may face barriers to accessing health insurance and experience financial hardship because of medical expenditures. We examined potential improvements in access to insurance for cancer survivors through adult Medicaid expansions and premium tax credits in the new insurance marketplaces under the Affordable Care Act (ACA)., Methods: Eligibility for Medicaid and premium tax credits was simulated for cancer survivors age 18 to 64 years in the 2008 to 2010 Medical Expenditure Panel Survey using a detailed deterministic model. Financial hardship was determined as: 1) delays or unmet need for medical, prescription, or dental care because of cost or insurance issues and/or 2) family out-of-pocket medical spending that was 20% or more of gross income. Descriptive analyses were stratified by whether the state of residence chose to expand Medicaid by January 2015. All statistical tests were two-sided., Results: Overall, 14.7% of 9.44 million cancer survivors were uninsured, with 18% reporting financial hardship. Under the ACA, 19% overall, 30% of the uninsured, and 39% of those reporting financial hardship would be Medicaid eligible. An additional 10% would be eligible for premium tax credits, with the remainder able to participate in the Marketplace without tax credits. However, 21% of uninsured cancer survivors in states not expanding Medicaid would be ineligible for assistance with coverage., Conclusions: Under the ACA, many of the uninsured and a larger proportion of survivors facing financial hardship will be eligible for Medicaid or premium tax credits in the Marketplaces. ACA implementation will dramatically enhance insurance availability and is likely to reduce financial hardship for vulnerable cancer survivors., (© The Author 2015. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.)

A study published in the Journal of the National Cancer Institute examines the impact of clinic-based interventions on reducing treatment inequities between Black and White women diagnosed with breast cancer. The interventions, including patient navigation, provider bias training, and real-time tracking dashboards, aim to improve equitable treatment. While the interventions successfully addressed treatment inequities, they did not eliminate survival differences between the two groups. The study suggests that additional efforts are needed to eliminate racial disparities in breast cancer outcomes, including addressing factors such as screening, social determinants of health, and systemic racism. [Extracted from the article]

Cancer research has led to remarkable advances in our understanding of cancer biology and strategies for prevention, screening and early detection, treatment, and survivorship care, resulting in declines in cancer mortality rates ([1]). Google Scholar Crossref Search ADS PubMed WorldCat 65 Richman I, Tessier-Sherman B, Galusha D, Oladele CR, Wang K. Breast cancer screening during the COVID-19 pandemic: moving from disparities to health equity. Google Scholar Crossref Search ADS PubMed WorldCat 32 Haghighat S, Jiang C, El-Rifai W, Zaika A, Goldberg DS, Kumar S. Urgent need to mitigate disparities in federal funding for cancer research. [Extracted from the article]

Background Medicaid expansion is associated with improved survival following cancer diagnosis. However, little research has assessed how changes in cancer stage may mediate improved cancer mortality or how expansion may have decreased population-level cancer mortality rates. Methods Nationwide state-level cancer data from 2001 to 2019 for individuals ages 20-64 years were obtained from the combined Surveillance, Epidemiology, and End Results National Program of Cancer Registries (incidence) and the National Center for Health Statistics (mortality) databases. We estimated changes in distant stage cancer incidence and cancer mortality rates from pre- to post-2014 in expansion vs nonexpansion states using generalized estimating equations with robust standard errors. Mediation analyses were used to assess whether distant stage cancer incidence mediated changes in cancer mortality. Results There were 17 370 state-level observations. For all cancers combined, there were Medicaid expansion–associated decreases in distant stage cancer incidence (adjusted odds ratio = 0.967, 95% confidence interval  = 0.943 to 0.992; P  = .01) and cancer mortality (adjusted odds ratio = 0.965, 95% confidence interval = 0.936 to 0.995; P  = .022). This translates to 2591 averted distant stage cancer diagnoses and 1616 averted cancer deaths in the Medicaid expansion states. Distant stage cancer incidence mediated 58.4% of expansion-associated changes in cancer mortality overall (P  = .008). By cancer site subgroups, there were expansion-associated decreases in breast, cervix, and liver cancer mortality. Conclusions Medicaid expansion was associated with decreased distant stage cancer incidence and cancer mortality. Approximately 60% of the expansion-associated changes in cancer mortality overall were mediated by distant stage diagnoses. [ABSTRACT FROM AUTHOR]

Previous studies using data from the early 2000s demonstrated that patients who were uninsured were more likely to present with late‐stage disease and had worse short‐term survival after cancer diagnosis in the United States. In this report, the authors provide comprehensive data on the associations of health insurance coverage type with stage at diagnosis and long‐term survival in individuals aged 18–64 years who were diagnosed between 2010 and 2013 with 19 common cancers from the National Cancer Database, with survival follow‐up through December 31, 2019. Compared with privately insured patients, Medicaid‐insured and uninsured patients were significantly more likely to be diagnosed with late‐stage (III/IV) cancer for all stageable cancers combined and separately. For all stageable cancers combined and for six cancer sites—prostate, colorectal, non‐Hodgkin lymphoma, oral cavity, liver, and esophagus—uninsured patients with Stage I disease had worse survival than privately insured patients with Stage II disease. Patients without private insurance coverage had worse short‐term and long‐term survival at each stage for all cancers combined; patients who were uninsured had worse stage‐specific survival for 12 of 17 stageable cancers and had worse survival for leukemia and brain tumors. Expanding access to comprehensive health insurance coverage is crucial for improving access to cancer care and outcomes, including stage at diagnosis and survival. [ABSTRACT FROM AUTHOR]

Background: Medicaid expansion under the Affordable Care Act (ACA) is associated with increased insurance coverage among patients with cancer. Whether these gains translate to improved survival is largely unknown. This study examines changes in 2-year survival among patients newly diagnosed with cancer following the ACA Medicaid expansion.Methods: Patients aged 18-62 years from 42 states' population-based cancer registries diagnosed pre (2010-2012) and post (2014-2016) ACA Medicaid expansion were followed through September 30, 2013, and December 31, 2017, respectively. Difference-in-differences (DD) analysis of 2-year overall survival was stratified by sex, race and ethnicity, census tract-level poverty, and rurality.Results: A total of 2 555 302 patients diagnosed with cancer were included from Medicaid expansion (n = 1 523 585) and nonexpansion (n = 1 031 717) states. The 2-year overall survival increased from 80.58% pre-ACA to 82.23% post-ACA in expansion states and from 78.71% to 80.04% in nonexpansion states, resulting in a net increase of 0.44 percentage points (ppt) (95% confidence interval [CI] = 0.24ppt to 0.64ppt) in expansion states after adjusting for sociodemographic factors. By cancer site, the net increase was greater for colorectal cancer (DD = 0.90ppt, 95% CI = 0.19ppt to 1.60ppt), lung cancer (DD = 1.29ppt, 95% CI = 0.50ppt to 2.08ppt), non-Hodgkin lymphoma (DD = 1.07ppt, 95% CI = 0.14ppt to 1.99ppt), pancreatic cancer (DD = 1.80ppt, 95% CI = 0.40ppt to 3.21ppt), and liver cancer (DD = 2.57ppt, 95% CI = 1.00ppt to 4.15ppt). The improvement in 2-year overall survival was larger among non-Hispanic Black patients (DD = 0.72ppt, 95% CI = 0.12ppt to 1.31ppt) and patients residing in rural areas (DD = 1.48ppt, 95% CI= -0.26ppt to 3.23ppt), leading to narrowing survival disparities by race and rurality.Conclusions: Medicaid expansion was associated with greater increase in 2-year overall survival, and the increase was prominent among non-Hispanic Blacks and in rural areas, highlighting the role of Medicaid expansion in reducing health disparities. Future studies should monitor changes in longer-term health outcomes following the ACA. [ABSTRACT FROM AUTHOR]

PURPOSE To examine the association between historic state Medicaid income eligibility limits and long-term survival among patients with cancer. METHODS 1,449,144 adults age 18-64 years newly diagnosed with 19 common cancers between 2010 and 2013 were identified from the National Cancer Database. States' Medicaid income eligibility limits were categorized as # 50%, 51%-137%, and $ 138% of federal poverty level (FPL). Survival time was measured from diagnosis date through December 31, 2017, for up to an 8-year follow-up. Multivariable Cox proportional hazards models with age as time scale were used to assess associations of eligibility limits and stage-specific survival, adjusting for the effects of sex, metropolitan statistical area, comorbidities, year of diagnosis, facility type and volume, and state. RESULTS Among patients with newly diagnosed cancer age 18-64 years, patients living in states with lower Medicaid income eligibility limits had worse survival for most cancers in both early and late stages, compared with those living in states with Medicaid income eligibility limits $ 138% FPL. A dose-response relationship was observed for most cancers with lower income limits associated with worse survival (13 of 17 cancers evaluated for early-stage cancers, and 11 of 17 cancers evaluated for late-stage cancers, and leukemia and brain tumors with P-trend < .05). CONCLUSION Lower Medicaid income eligibility limits were associated with worse long-term survival within stage; increasing Medicaid income eligibility may improve survival after cancer diagnosis. [ABSTRACT FROM AUTHOR]

Background: Young 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.Methods: Using 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.Results: The 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.Conclusions: We 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. [ABSTRACT FROM AUTHOR]

Background: Little is known about changes in socioeconomic disparities in noninsurance and care unaffordability among nonelderly cancer survivors following the Affordable Care Act (ACA).Methods: Cancer survivors aged 18-64 years nationwide were identified from the Behavioral Risk Factor Surveillance System. Trend and difference-in-differences analyses were conducted to examine changes in percent uninsured and percent reporting care unaffordability pre-(2011 to 2013) and post-(2014 to 2017) ACA Medicaid expansion, by sociodemographic factors.Results: A total of 118 631 cancer survivors were identified from Medicaid expansion (n = 72 124) and nonexpansion (n = 46 507) states. Following the ACA, percent uninsured and percent reporting care unaffordability decreased nationwide. Medicaid expansion was associated with a 1.8 (95% confidence interval [CI] = 0.1 to 3.5) percentage points (ppt) net decrease in noninsurance and a 2.9 (95% CI = 0.7 to 5.1) ppt net decrease in care unaffordability. In stratified analyses by sociodemographic factors, substantial decreases were observed in female survivors, those with low or medium household incomes, the unemployed, and survivors with multiple comorbidities. However, we observed slightly increased percentages in reporting noninsurance (ppt = 1.7; 95% CI = -1.2 to 4.5) and care unaffordability (ppt = 3.1, 95% CI = -0.4 to 6.5) in nonexpansion states between 2016 and 2017, translating to 67 163 and 124 160 survivors, respectively.Conclusion: We observed reductions in disparities by sociodemographic factors in noninsurance and care unaffordability among nonelderly cancer survivors following the ACA, with largest decreases in women, those with low or medium income, multiple comorbid conditions, the unemployed, and those residing in Medicaid expansion states. However, the uptick of 82 750 uninsured survivors in 2017, mainly from nonexpansion states, is concerning. Ongoing monitoring of the effects of the ACA is warranted, especially in evaluating health outcomes. [ABSTRACT FROM AUTHOR]

Background: Use of genomic testing is increasing in the United States. Testing can be expensive, and not all tests and related treatments are covered by health insurance. Little is known about how often oncologists discuss costs of testing and treatment or about the factors associated with those discussions.Methods: We identified 1220 oncologists who reported discussing genomic testing with their cancer patients from the 2017 National Survey of Precision Medicine in Cancer Treatment. Multivariable polytomous logistic regression analyses were used to assess associations between oncologist and practice characteristics and the frequency of cost discussions. All statistical tests were two-sided.Results: Among oncologists who discussed genomic testing with patients, 50.0% reported often discussing the likely costs of testing and related treatments, 26.3% reported sometimes discussing costs, and 23.7% reported never or rarely discussing costs. In adjusted analyses, oncologists with training in genomic testing or working in practices with electronic medical record alerts for genomic tests were more likely to have cost discussions sometimes (odds ratio [OR] = 2.09, 95% confidence interval [CI] = 1.19 to 3.69) or often (OR = 2.22, 95% CI = 1.30 to 3.79), respectively, compared to rarely or never. Other factors statistically significantly associated with more frequent cost discussions included treating solid tumors (rather than only hematological cancers), using next-generation sequencing gene panel tests, having higher patient volume, and working in practices with higher percentages of patients insured by Medicaid, or self-paid or uninsured.Conclusions: Interventions targeting modifiable oncologist and practice factors, such as training in genomic testing and use of electronic medical record alerts, may help improve cost discussions about genomic testing and related treatments. [ABSTRACT FROM AUTHOR]

Background: To the authors' knowledge, little is known regarding the impact of the Patient Protection and Affordable Care Act (ACA) on people living with HIV and cancer (PLWHC), who have lower cancer treatment rates and worse cancer outcomes. To investigate this research gap, the authors examined the effects of the ACA on insurance coverage and receipt of cancer treatment among PLWHC in the United States.Methods: HIV-infected individuals aged 18 to 64 years old with cancer diagnosed between 2011 and 2015 were identified in the National Cancer Data Base. Health insurance coverage and cancer treatment receipt were compared before and after implementation of the ACA in non-Medicaid expansion and Medicaid expansion states using difference-in-differences analysis.Results: Of the 4794 PLWHC analyzed, approximately 49% resided in nonexpansion states and were more often uninsured (16.7% vs 4.2%), nonwhite (65.2% vs 60.2%), and of low income (36.3% vs 26.9%) compared with those in Medicaid expansion states. After 2014, the percentage of uninsured individuals decreased in expansion states (from 4.9% to 3%; P = .01) and nonexpansion states (from 17.6% to 14.6%; P = .06), possibly due to increased Medicaid coverage in expansion states (from 36.9% to 39.2%) and increased private insurance coverage in nonexpansion states (from 29.5% to 34.7%). There was no significant difference in cancer treatment receipt noted between Medicaid expansion and nonexpansion states. However, the percentage of PLWHC treated at academic facilities increased significantly only in expansion states (from 40.2% to 46.7% [P < .0001]; difference-in-differences analysis: 7.2 percentage points [P = .02]).Conclusions: The implementation of the ACA was associated with improved insurance coverage among PLWHC. Lack of insurance still is common in non-Medicaid expansion states. Patients with minority or low socioeconomic status more often resided in nonexpansion states, thereby highlighting the need for further insurance expansion. [ABSTRACT FROM AUTHOR]

Background: Cancer survivors may face barriers to accessing health insurance and experience financial hardship because of medical expenditures. We examined potential improvements in access to insurance for cancer survivors through adult Medicaid expansions and premium tax credits in the new insurance marketplaces under the Affordable Care Act (ACA).Methods: Eligibility for Medicaid and premium tax credits was simulated for cancer survivors age 18 to 64 years in the 2008 to 2010 Medical Expenditure Panel Survey using a detailed deterministic model. Financial hardship was determined as: 1) delays or unmet need for medical, prescription, or dental care because of cost or insurance issues and/or 2) family out-of-pocket medical spending that was 20% or more of gross income. Descriptive analyses were stratified by whether the state of residence chose to expand Medicaid by January 2015. All statistical tests were two-sided.Results: Overall, 14.7% of 9.44 million cancer survivors were uninsured, with 18% reporting financial hardship. Under the ACA, 19% overall, 30% of the uninsured, and 39% of those reporting financial hardship would be Medicaid eligible. An additional 10% would be eligible for premium tax credits, with the remainder able to participate in the Marketplace without tax credits. However, 21% of uninsured cancer survivors in states not expanding Medicaid would be ineligible for assistance with coverage.Conclusions: Under the ACA, many of the uninsured and a larger proportion of survivors facing financial hardship will be eligible for Medicaid or premium tax credits in the Marketplaces. ACA implementation will dramatically enhance insurance availability and is likely to reduce financial hardship for vulnerable cancer survivors. [ABSTRACT FROM AUTHOR]

Despite clinical benefits of early palliative care, little is known about Medicare physician workforce specialized in Hospice and Palliative Medicine (HPM) and their service delivery settings. To examine changes in Medicare HPM physician workforce and their service delivery settings in 2008–2020. Using the Medicare Data on Provider Practice and Specialty from 2008 to 2020, we identified 2375 unique Medicare Fee-For-Service (FFS) physicians (15,565 physician-year observations) with self-reported specialty in "Palliative Care and Hospice". We examined changes in the annual number of HPM physicians, average number of Medicare services overall and by care setting, total number of Medicare FFS beneficiaries, and total Medicare allowed charges billed by the physician. The number of Medicare HPM physicians increased 2.32 times from 771 in 2008 to 1790 in 2020. The percent of HPM physicians practicing in metropolitan areas increased from 90% to 96% in 2008–2020. Faster growth was also observed in female physicians (52.4% to 60.1%). Between 2008 and 2020, we observed decreased average annual Medicare FFS beneficiaries (170 to 123), number of FFS services (467 to 335), and Medicare allowed charges billed by the physician ($47,230 to $37,323). The share of palliative care delivered in inpatient settings increased from 47% to 68% in 2008–2020; whereas the share of services delivered in outpatient settings decreased from 37% to 19%. Despite growth in Medicare HPM physician workforce, access is disproportionately concentrated in metropolitan and inpatient settings. This may limit receipt of early outpatient specialized palliative care, especially in nonmetropolitan areas. [ABSTRACT FROM AUTHOR]

The dependent coverage expansion (DCE) and Medicaid expansions (ME) under the Affordable Care Act (ACA) may differentially affect eligibility for health insurance coverage in young adult cancer patients. Studies examining temporal patterns of coverage changes in young adults following these policies are lacking. We used data from the National Cancer Database 2003–2015 to conduct a quasi-experimental study of cancer patients ages 19–34 years, grouped as DCE-eligible (19- to 25-year-olds) and DCE-ineligible (27- to 34-year-olds). Although private insurance coverage in DCE-eligible cancer patients increased incrementally following DCE implementation (0.5 per quarter; P <.001), an immediate effect on Medicaid coverage gains was observed after ME in all young adult cancer patients (3.01 for DCE-eligible and 1.62 for DCE-ineligible, both P <.001). Therefore, DCE and ME each had statistically significant and distinct effects on insurance coverage gains. Distinct temporal patterns of ACA policies' impact on insurance coverage gains likely affect patterns of receipt of cancer care. Temporal patterns should be considered when evaluating the impact of health policies. [ABSTRACT FROM AUTHOR]