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García MC, Rossen LM, Matthews K, Guy G, Trivers KF, Thomas CC, Schieb L, Iademarco MF. Preventable Premature Deaths from the Five Leading Causes of Death in Nonmetropolitan and Metropolitan Counties, United States, 2010-2022. MORBIDITY AND MORTALITY WEEKLY REPORT. SURVEILLANCE SUMMARIES (WASHINGTON, D.C. : 2002) 2024; 73:1-11. [PMID: 38687830 PMCID: PMC11065459 DOI: 10.15585/mmwr.ss7302a1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
Problem/Condition A 2019 report quantified the higher percentage of potentially excess (preventable) deaths in U.S. nonmetropolitan areas compared with metropolitan areas during 2010-2017. In that report, CDC compared national, regional, and state estimates of preventable premature deaths from the five leading causes of death in nonmetropolitan and metropolitan counties during 2010-2017. This report provides estimates of preventable premature deaths for additional years (2010-2022). Period Covered 2010-2022. Description of System Mortality data for U.S. residents from the National Vital Statistics System were used to calculate preventable premature deaths from the five leading causes of death among persons aged <80 years. CDC's National Center for Health Statistics urban-rural classification scheme for counties was used to categorize the deaths according to the urban-rural county classification level of the decedent's county of residence (1: large central metropolitan [most urban], 2: large fringe metropolitan, 3: medium metropolitan, 4: small metropolitan, 5: micropolitan, and 6: noncore [most rural]). Preventable premature deaths were defined as deaths among persons aged <80 years that exceeded the number expected if the death rates for each cause in all states were equivalent to those in the benchmark states (i.e., the three states with the lowest rates). Preventable premature deaths were calculated separately for the six urban-rural county categories nationally, the 10 U.S. Department of Health and Human Services public health regions, and the 50 states and the District of Columbia. Results During 2010-2022, the percentage of preventable premature deaths among persons aged <80 years in the United States increased for unintentional injury (e.g., unintentional poisoning including drug overdose, unintentional motor vehicle traffic crash, unintentional drowning, and unintentional fall) and stroke, decreased for cancer and chronic lower respiratory disease (CLRD), and remained stable for heart disease. The percentages of preventable premature deaths from the five leading causes of death were higher in rural counties in all years during 2010-2022. When assessed by the six urban-rural county classifications, percentages of preventable premature deaths in the most rural counties (noncore) were consistently higher than in the most urban counties (large central metropolitan and fringe metropolitan) for the five leading causes of death during the study period.During 2010-2022, preventable premature deaths from heart disease increased most in noncore (+9.5%) and micropolitan counties (+9.1%) and decreased most in large central metropolitan counties (-10.2%). Preventable premature deaths from cancer decreased in all county categories, with the largest decreases in large central metropolitan and large fringe metropolitan counties (-100.0%; benchmark achieved in both county categories in 2019). In all county categories, preventable premature deaths from unintentional injury increased, with the largest increases occurring in large central metropolitan (+147.5%) and large fringe metropolitan (+97.5%) counties. Preventable premature deaths from CLRD decreased most in large central metropolitan counties where the benchmark was achieved in 2019 and increased slightly in noncore counties (+0.8%). In all county categories, preventable premature deaths from stroke decreased from 2010 to 2013, remained constant from 2013 to 2019, and then increased in 2020 at the start of the COVID-19 pandemic. Percentages of preventable premature deaths varied across states by urban-rural county classification during 2010-2022. Interpretation During 2010-2022, nonmetropolitan counties had higher percentages of preventable premature deaths from the five leading causes of death than did metropolitan counties nationwide, across public health regions, and in most states. The gap between the most rural and most urban counties for preventable premature deaths increased during 2010-2022 for four causes of death (cancer, heart disease, CLRD, and stroke) and decreased for unintentional injury. Urban and suburban counties (large central metropolitan, large fringe metropolitan, medium metropolitan, and small metropolitan) experienced increases in preventable premature deaths from unintentional injury during 2010-2022, leading to a narrower gap between the already high (approximately 69% in 2022) percentage of preventable premature deaths in noncore and micropolitan counties. Sharp increases in preventable premature deaths from unintentional injury, heart disease, and stroke were observed in 2020, whereas preventable premature deaths from CLRD and cancer continued to decline. CLRD deaths decreased during 2017-2020 but increased in 2022. An increase in the percentage of preventable premature deaths for multiple leading causes of death was observed in 2020 and was likely associated with COVID-19-related conditions that contributed to increased mortality from heart disease and stroke. Public Health Action Routine tracking of preventable premature deaths based on urban-rural county classification might enable public health departments to identify and monitor geographic disparities in health outcomes. These disparities might be related to different levels of access to health care, social determinants of health, and other risk factors. Identifying areas with a high prevalence of potentially preventable mortality might be informative for interventions.
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Thompson CA, Nianogo RA, Leonard T. Unaffordable housing and cancer: novel insights into a complex question. JNCI Cancer Spectr 2024; 8:pkae029. [PMID: 38708930 PMCID: PMC11071115 DOI: 10.1093/jncics/pkae029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 03/24/2024] [Indexed: 05/07/2024] Open
Affiliation(s)
- Caroline A Thompson
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Center for Health Promotion and Disease Prevention, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Roch A Nianogo
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
| | - Tammy Leonard
- Department of Health Economics and Policy, O’Donnell School of Public Health and Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
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Barnes JM, Johnson KJ, Osazuwa-Peters N, Spraker MB. The impact of individual-level income predicted from the BRFSS on the association between insurance status and overall survival among adults with cancer from the SEER program. Cancer Epidemiol 2024; 89:102541. [PMID: 38325026 DOI: 10.1016/j.canep.2024.102541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 01/06/2024] [Accepted: 01/22/2024] [Indexed: 02/09/2024]
Abstract
INTRODUCTION Among patients with cancer in the United States, Medicaid insurance is associated with worse outcomes than private insurance and with similar outcomes as being uninsured. However, prior studies have not addressed the impact of individual-level socioeconomic status, which determines Medicaid eligibility, on the associations of Medicaid status and cancer outcomes. Our objective was to determine whether differences in cancer outcomes by insurance status persist after accounting for individual-level income. METHODS The Surveillance, Epidemiology, and End Results (SEER) database was queried for 18-64 year-old individuals with cancer from 2014-2016. Individual-level income was imputed using a model trained on Behavioral Risk Factors Surveillance Survey participants including covariates also present in SEER. The association of 1-year overall survival and insurance status was estimated with and without adjustment for estimated individual-level income and other covariates. RESULTS A total of 416,784 cases in SEER were analyzed. The 1-yr OS for patients with private insurance, Medicaid insurance, and no insurance was 88.7%, 76.1%, and 73.7%, respectively. After adjusting for all covariates except individual-level income, 1-year OS differences were worse with Medicaid (-6.0%, 95% CI = -6.3 to -5.6) and no insurance (-6.7%, 95% CI = -7.3 to -6.0) versus private insurance. After also adjusting for estimated individual-level income, the survival difference for Medicaid patients was similar to privately insured (-0.4%, 95% CI = -1.9 to 1.1) and better than uninsured individuals (2.1%, 95% CI = 0.7 to 3.4). CONCLUSIONS Income, rather than Medicaid status, may drive poor cancer outcomes in the low-income and Medicaid-insured population. Medicaid insurance coverage may improve cancer outcomes for low-income individuals.
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Affiliation(s)
- Justin M Barnes
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, Saint Louis, MO, USA.
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Nianogo RA, Zhao F, Li S, Nishi A, Basu S. Medicaid Expansion and Racial-Ethnic and Sex Disparities in Cardiovascular Diseases Over 6 Years: A Generalized Synthetic Control Approach. Epidemiology 2024; 35:263-272. [PMID: 38290145 DOI: 10.1097/ede.0000000000001691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
BACKGROUND Studies have suggested Medicaid expansion enacted in 2014 has resulted in a reduction in overall cardiovascular disease (CVD) mortality in the United States. However, it is unknown whether Medicaid expansion has a similar effect across race-ethnicity and sex. We investigated the effect of Medicaid expansion on CVD mortality across race-ethnicity and sex. METHODS Data come from the behavioral risk factor surveillance system and the US Centers for Disease Control's Wide-ranging Online Data for Epidemiologic Research, spanning the period 2000-2019. We used the generalized synthetic control method, a quasi-experimental approach, to estimate effects. RESULTS Medicaid expansion was associated with -5.36 (mean difference [MD], 95% confidence interval [CI] = -22.63, 11.91) CVD deaths per 100,000 persons per year among Blacks; -4.28 (MD, 95% CI = -30.08, 21.52) among Hispanics; -3.18 (MD, 95% CI = -8.30, 1.94) among Whites; -5.96 (MD, 95% CI = -15.42, 3.50) among men; and -3.34 (MD, 95% CI = -8.05, 1.37) among women. The difference in mean difference (DMD) between the effect of Medicaid expansion in Blacks compared with Whites was -2.18; (DMD, 95% CI = -20.20, 15.83); between that in Hispanics compared with Whites: -1.10; (DMD, 95% CI = -27.40, 25.20) and between that in women compared with men: 2.62; (DMD, 95% CI = -7.95, 13.19). CONCLUSIONS Medicaid expansion was associated with a reduction in CVD mortality overall and in White, Black, Hispanic, male, and female subpopulations. Also, our study did not find any difference or disparity in the effect of Medicaid on CVD across race-ethnicity and sex-gender subpopulations, likely owing to imprecise estimates.
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Affiliation(s)
- Roch A Nianogo
- From the Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, CA
- California Center for Population Research, UCLA, Los Angeles, CA
| | - Fan Zhao
- From the Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, CA
- California Center for Population Research, UCLA, Los Angeles, CA
| | - Stephen Li
- Los Angeles County Department of Public Health (LACDPH), Los Angeles, CA
| | - Akihiro Nishi
- From the Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, CA
- California Center for Population Research, UCLA, Los Angeles, CA
- Bedari Kindness Institute, University of California, Los Angeles, Los Angeles, CA
| | - Sanjay Basu
- Center for Primary Care, Harvard Medical School, Boston, MA
- Research and Development, Waymark, San Francisco, CA
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Arch RS, Fei-Zhang DJ, Patel U, Rastatter JC. Influence of Medicaid Expansion on Head and Neck Squamous Cell Carcinoma Presentation and Survival. Otolaryngol Head Neck Surg 2024; 170:431-437. [PMID: 37811691 DOI: 10.1002/ohn.552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 08/24/2023] [Accepted: 09/02/2023] [Indexed: 10/10/2023]
Abstract
OBJECTIVE To compare head and neck squamous cell carcinoma stage at presentation and survival in Medicaid-expanded states versus nonexpanded states. STUDY DESIGN Retrospective cohort. SETTING Northwestern University Feinberg School of Medicine. METHODS The Head and Neck with human papillomavirus Status Database within the Surveillance, Epidemiology, and End Results (SEER) Program was queried for cases of head and neck squamous cell carcinoma (HNSCC) diagnosed in the years 2010 to 2016. Cases were grouped according to their respective state Medicaid expansion status. Multivariable logistic regressions and multivariable Cox proportional hazards models were used to evaluate associations with stage IV disease and survival. RESULTS Compared to nonexpanded states, Medicaid-expanded states had a significantly larger proportion of Medicaid patients (20.3% vs 16.7%, P = .0009) and a significantly smaller proportion of uninsured patients (1.7% vs 10.1%, P < .0001). The case selection process resulted in 2215 patients meeting inclusion criteria. In multivariable analysis, cases under Medicaid expansion were 31% less likely to present with stage IV disease compared to cases in nonexpanded states (odds ratio: 0.69, 95% confidence interval [CI]: 0.51-0.93). In the multivariable Cox proportional hazards model, cases under Medicaid expansion had significantly better mortality outcomes and were 32% less likely to die compared to cases in nonexpanded states (hazard ratio: 0.68, 95% CI: 0.55-0.84). CONCLUSION Medicaid expansion is associated with fewer stage IV cases and improved survival of HNSCC cases. These findings support continued efforts to expand Medicaid coverage.
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Affiliation(s)
- Rebecca Sinard Arch
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - David J Fei-Zhang
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Urjeet Patel
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jeffrey C Rastatter
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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Mobley EM, Chen G, Xu J, Edgar L, Pather K, Daly MC, Awad ZT, Parker AS, Xie Z, Suk R, Mathews S, Hong YR. Association of Medicaid expansion with 2-year survival and time to treatment initiation in gastrointestinal cancer patients: A National Cancer Database study. J Surg Oncol 2023; 128:1285-1301. [PMID: 37781956 DOI: 10.1002/jso.27456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/10/2023] [Accepted: 09/17/2023] [Indexed: 10/03/2023]
Abstract
INTRODUCTION We evaluated whether Medicaid expansion (ME) was associated with improved 2-year survival and time to treatment initiation (TTI) among patients with gastrointestinal (GI) cancer. METHODS GI cancer patients diagnosed 40-64 years were queried from the National Cancer Database. Those diagnosed from 2010 to 2012 were considered pre-expansion; those diagnosed from 2014 to 2016 were considered post-expansion. Cox models estimated hazard ratios and 95% confidence intervals (CIs) for 2-year overall survival. Generalized estimating equations (GEE) estimated odds ratios (OR) and 95% CI of TTI within 30- and 90 days. Multivariable Difference-in-Difference models were used to compare expansion/nonexpansion cohorts pre-/post-expansion, adjusting for patient, clinical, and hospital factors. RESULTS 377,063 patients were included. No significant difference in 2-year survival was demonstrated across ME and non-ME states overall or in site-based subgroup analysis. In stage-based subgroup analysis, 2-year survival significantly improved among stage II cancer, with an 8% decreased hazard of death at 2 years (0.92; 0.87-0.97). Those with stage IV had a 4% increased hazard of death at 2 years (1.04; 1.01-1.07). Multivariable GEE models showed increased TTI within 30 days (1.12; 1.09-1.16) and 90 days (1.22; 1.17-1.27). Site-based subgroup analyses indicated increased likelihood of TTI within 30 and 90 days among colon, liver, pancreas, rectum, and stomach cancers, by 30 days for small intestinal cancer, and by 90 days for esophageal cancer. In subgroup analyses, all stages experienced improved odds of TTI within 30 and 90 days. CONCLUSION ME was not associated with significant improvement in 2-year survival for those with GI cancer. Although TTI increased after ME for both cohorts, the 30- and 90-day odds of TTI was higher for those from ME compared with non-ME states. Our findings add to growing evidence of associations with ME for those diagnosed with GI cancer.
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Affiliation(s)
- Erin M Mobley
- Division of General Surgery and Surgical Oncology, Department of Surgery, College of Medicine, University of Florida, Jacksonville, Florida, USA
| | - Guanming Chen
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Jie Xu
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Lauren Edgar
- Division of General Surgery and Surgical Oncology, Department of Surgery, College of Medicine, University of Florida, Jacksonville, Florida, USA
| | - Keouna Pather
- Division of General Surgery and Surgical Oncology, Department of Surgery, College of Medicine, University of Florida, Jacksonville, Florida, USA
| | - Meghan C Daly
- Division of General Surgery and Surgical Oncology, Department of Surgery, College of Medicine, University of Florida, Jacksonville, Florida, USA
| | - Ziad T Awad
- Division of General Surgery and Surgical Oncology, Department of Surgery, College of Medicine, University of Florida, Jacksonville, Florida, USA
| | | | - Zhigang Xie
- Department of Public Health, University of North Florida, Jacksonville, Florida, USA
| | - Ryan Suk
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Simon Mathews
- Division of Gastroenterology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Young-Rock Hong
- Department of Health Services Research, Management, and Policy, College of Public Health and Health Professions, University of Florida, Gainesville, Florida, USA
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Chapman C, Jayasekera J, Dash C, Sheppard V, Mandelblatt J. A health equity framework to support the next generation of cancer population simulation models. J Natl Cancer Inst Monogr 2023; 2023:255-264. [PMID: 37947339 PMCID: PMC10846912 DOI: 10.1093/jncimonographs/lgad017] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/03/2023] [Accepted: 06/22/2023] [Indexed: 11/12/2023] Open
Abstract
Over the past 2 decades, population simulation modeling has evolved as an effective public health tool for surveillance of cancer trends and estimation of the impact of screening and treatment strategies on incidence and mortality, including documentation of persistent cancer inequities. The goal of this research was to provide a framework to support the next generation of cancer population simulation models to identify leverage points in the cancer control continuum to accelerate achievement of equity in cancer care for minoritized populations. In our framework, systemic racism is conceptualized as the root cause of inequity and an upstream influence acting on subsequent downstream events, which ultimately exert physiological effects on cancer incidence and mortality and competing comorbidities. To date, most simulation models investigating racial inequity have used individual-level race variables. Individual-level race is a proxy for exposure to systemic racism, not a biological construct. However, single-level race variables are suboptimal proxies for the multilevel systems, policies, and practices that perpetuate inequity. We recommend that future models designed to capture relationships between systemic racism and cancer outcomes replace or extend single-level race variables with multilevel measures that capture structural, interpersonal, and internalized racism. Models should investigate actionable levers, such as changes in health care, education, and economic structures and policies to increase equity and reductions in health-care-based interpersonal racism. This integrated approach could support novel research approaches, make explicit the effects of different structures and policies, highlight data gaps in interactions between model components mirroring how factors act in the real world, inform how we collect data to model cancer equity, and generate results that could inform policy.
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Affiliation(s)
- Christina Chapman
- Department of Radiation Oncology, Baylor College of Medicine, and the Center for Innovations in Quality, Effectiveness, and Safety in the Department of Medicine, Baylor College of Medicine and the Houston VA, Houston, TX, USA
| | - Jinani Jayasekera
- Health Equity and Decision Sciences Research Laboratory, National Institute on Minority Health and Health Disparities, Intramural Research Program, National Institutes of Health, Bethesda, MD, USA
| | - Chiranjeev Dash
- Office of Minority Health and Health Disparities Research and Cancer Prevention and Control Program, Georgetown Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - Vanessa Sheppard
- Department of Health Behavior and Policy and Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Jeanne Mandelblatt
- Departments of Oncology and Medicine, Georgetown University Medical Center, Cancer Prevention and Control Program at Georgetown Lombardi Comprehensive Cancer Center and the Georgetown Lombardi Institute for Cancer and Aging Research, Washington, DC, USA
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Fitzgerald TL, Fitzgerald LR. Affordable Care Act Medicaid Expansion Association with Improved Cancer Outcomes: Quality at What Cost? Ann Surg Oncol 2023; 30:6965-6966. [PMID: 37668762 DOI: 10.1245/s10434-023-14087-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 07/24/2023] [Indexed: 09/06/2023]
Affiliation(s)
- Timothy L Fitzgerald
- Division of Surgical Oncology, Tufts University School of Medicine-Maine Medical Center, Portland, ME, USA.
| | - Liam R Fitzgerald
- Division of Surgical Oncology, Tufts University School of Medicine-Maine Medical Center, Portland, ME, USA
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Bacorn C, Serrano M, Lin LK. Review of sociodemographic risk factors for presentation with advanced non-melanoma skin cancer. Orbit 2023; 42:481-486. [PMID: 36120852 DOI: 10.1080/01676830.2022.2123930] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 09/06/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE Non-melanoma skin cancers (NMSC) are often localized and associated with an excellent prognosis but a minority present with locally advanced or metastatic disease requiring extensive resection or systemic treatment. Medical factors that increase the risk of advanced skin cancers such as tobacco use, systemic immunosuppression or genetic syndromes have been described but the sociodemographic risk factors are relatively uninvestigated and under reported. In this review a cohort of patients presenting with periorbital NMSC is reviewed for social determinants of health correlated with presentation with advanced disease. METHODS Patients presenting with periorbital NMSC during a 10-year period are categorized as advanced (those tumors requiring extensive local resection, sacrifice of the globe or systemic therapy) or non-advanced and demographic features are compared between the two groups. RESULTS 274 cases of periorbital NMSC were classified as either non-advanced (177) or advanced (97). Patients with public safety net health insurance were twice as likely to present with advanced disease (25% vs 13%). Patients with advanced disease were significantly less likely to be under the care of a primary care physician, lived in economically depressed areas with lower mean household incomes, and lived further from tertiary medical care. CONCLUSION Financial and sociodemographic features are strongly associated with presentation with advanced NMSC. Further work is needed to determine which sociodemographic features are independent risk factors. A better understanding of the relevant barriers to care may reduce the burden of advanced disease at presentation in the future.
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Affiliation(s)
- Colin Bacorn
- Johns Hopkins Medicine, Wilmer Eye Institute, Baltimore, Maryland, USA
| | - Melissa Serrano
- UC Davis School of Medicine, University of California Davis Health, Sacramento, California, USA
| | - Lily Koo Lin
- Department of Ophthalmology & Vision Science, University of California Davis Health, Sacramento, California, USA
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Barnes JM, Johnston KJ, Johnson KJ, Chino F, Osazuwa-Peters N. State Public Assistance Spending and Survival Among Adults With Cancer. JAMA Netw Open 2023; 6:e2332353. [PMID: 37669050 PMCID: PMC10481229 DOI: 10.1001/jamanetworkopen.2023.32353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 07/29/2023] [Indexed: 09/06/2023] Open
Abstract
Importance Social determinants of health contribute to disparities in cancer outcomes. State public assistance spending, including Medicaid and cash assistance programs for socioeconomically disadvantaged individuals, may improve access to care; address barriers, such as food and housing insecurity; and lead to improved cancer outcomes for marginalized populations. Objective To determine whether state-level public assistance spending is associated with overall survival (OS) among individuals with cancer, overall and by race and ethnicity. Design, Setting, and Participants This cohort study included US adults aged at least 18 years with a new cancer diagnosis from 2007 to 2013, with follow-up through 2019. Data were obtained from the Surveillance, Epidemiology, and End Results program. Data were analyzed from November 18, 2021, to July 6, 2023. Exposure Differential state-level public assistance spending. Main Outcome and Measure The main outcome was 6-year OS. Analyses were adjusted for age, race, ethnicity, sex, metropolitan residence, county-level income, state fixed effects, state-level percentages of residents living in poverty and aged 65 years or older, cancer type, and cancer stage. Results A total 2 035 977 individuals with cancer were identified and included in analysis, with 1 005 702 individuals (49.4%) aged 65 years or older and 1 026 309 (50.4%) male. By tertile of public assistance spending, 6-year OS was 55.9% for the lowest tertile, 55.9% for the middle tertile, and 56.6% for the highest tertile. In adjusted analyses, public assistance spending at the state-level was significantly associated with higher 6-year OS (0.09% [95% CI, 0.04%-0.13%] per $100 per capita; P < .001), particularly for non-Hispanic Black individuals (0.29% [95% CI, 0.07%-0.52%] per $100 per capita; P = .01) and non-Hispanic White individuals (0.12% [95% CI, 0.08%-0.16%] per $100 per capita; P < .001). In sensitivity analyses examining the roles of Medicaid spending and Medicaid expansion including additional years of data, non-Medicaid spending was associated with higher 3-year OS among non-Hispanic Black individuals (0.49% [95% CI, 0.26%-0.72%] per $100 per capita when accounting for Medicaid spending; 0.17% [95% CI, 0.02%-0.31%] per $100 per capita Medicaid expansion effects). Conclusions and Relevance This cohort study found that state public assistance expenditures, including cash assistance programs and Medicaid, were associated with improved survival for individuals with cancer. State investment in public assistance programs may represent an important avenue to improve cancer outcomes through addressing social determinants of health and should be a topic of further investigation.
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Affiliation(s)
- Justin M. Barnes
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Kenton J. Johnston
- General Medical Sciences Division, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | | | - Fumiko Chino
- Department of Radiation Oncology, Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nosayaba Osazuwa-Peters
- Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, North Carolina
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina
- Duke Cancer Institute, Duke University, Durham, North Carolina
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Balakrishnan K, Faucett EA, Villwock J, Boss EF, Esianor BI, Jefferson GD, Graboyes EM, Thompson DM, Flanary VA, Brenner MJ. Allyship to Advance Diversity, Equity, and Inclusion in Otolaryngology: What We Can All Do. CURRENT OTORHINOLARYNGOLOGY REPORTS 2023; 11:201-214. [PMID: 38073717 PMCID: PMC10707492 DOI: 10.1007/s40136-023-00467-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2023] [Indexed: 01/31/2024]
Abstract
Purpose of review To summarize the current literature on allyship, providing a historical perspective, concept analysis, and practical steps to advance equity, diversity, and inclusion. This review also provides evidence-based tools to foster allyship and identifies potential pitfalls. Recent findings Allies in healthcare advocate for inclusive and equitable practices that benefit patients, coworkers, and learners. Allyship requires working in solidarity with individuals from underrepresented or historically marginalized groups to promote a sense of belonging and opportunity. New technologies present possibilities and perils in paving the pathway to diversity. Summary Unlocking the power of allyship requires that allies confront unconscious biases, engage in self-reflection, and act as effective partners. Using an allyship toolbox, allies can foster psychological safety in personal and professional spaces while avoiding missteps. Allyship incorporates goals, metrics, and transparent data reporting to promote accountability and to sustain improvements. Implementing these allyship strategies in solidarity holds promise for increasing diversity and inclusion in the specialty.
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Affiliation(s)
- Karthik Balakrishnan
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Erynne A. Faucett
- Department of Otolaryngology-Head and Neck Surgery, University of CA-Davis , Sacramento, USA
| | - Jennifer Villwock
- Department of Otolaryngology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Emily F. Boss
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Brandon I. Esianor
- Department of Otolaryngology-Head & Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gina D. Jefferson
- Department of Otolaryngology-Head and Neck Surgery, The University of Mississippi Medical Center, Jackson, MS, USA
| | - Evan M. Graboyes
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, USA
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, USA
| | - Dana M. Thompson
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
- Feinberg School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Northwestern University, Chicago, IL, USA
| | - Valerie A. Flanary
- Division of Pediatric Otolaryngology, Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Michael J. Brenner
- Department of Otolaryngology–Head & Neck Surgery, University of Michigan medical School, 1500 East Medical Center Drive, 48108 Ann Arbor, MI, USA
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12
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Barnes JM, Johnson KJ, Osazuwa-Peters N, Yabroff KR, Chino F. Changes in cancer mortality after Medicaid expansion and the role of stage at diagnosis. J Natl Cancer Inst 2023; 115:962-970. [PMID: 37202350 PMCID: PMC10407703 DOI: 10.1093/jnci/djad094] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/12/2023] [Accepted: 05/15/2023] [Indexed: 05/20/2023] Open
Abstract
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.
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Affiliation(s)
- Justin M Barnes
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Nosayaba Osazuwa-Peters
- Department of Otolaryngology-Head and Neck Surgery, Duke University, Durham, NC, USA
- Duke Cancer Institute, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - K Robin Yabroff
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA, USA
| | - Fumiko Chino
- Department of Radiation Oncology, Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Hotca A, Bloom JR, Runnels J, Salgado LR, Cherry DR, Hsieh K, Sindhu KK. The Impact of Medicaid Expansion on Patients with Cancer in the United States: A Review. Curr Oncol 2023; 30:6362-6373. [PMID: 37504329 PMCID: PMC10378187 DOI: 10.3390/curroncol30070469] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/25/2023] [Accepted: 06/28/2023] [Indexed: 07/29/2023] Open
Abstract
Since 2014, American states have had the option to expand their Medicaid programs as part of the Affordable Care Act (ACA), which was signed into law by former President Barack H. Obama in 2010. Emerging research has found that Medicaid expansion has had a significant impact on patients with cancer, who often face significant financial barriers to receiving the care they need. In this review, we aim to provide a comprehensive examination of the research conducted thus far on the impact of Medicaid expansion on patients with cancer. We begin with a discussion of the history of Medicaid expansion and the key features of the ACA that facilitated it. We then review the literature, analyzing studies that have investigated the impact of Medicaid expansion on cancer patients in terms of access to care, quality of care, and health outcomes. Our findings suggest that Medicaid expansion has had a positive impact on patients with cancer in a number of ways. Patients in expansion states are more likely to receive timely cancer screening and diagnoses, and are more likely to receive appropriate cancer-directed treatment. Additionally, Medicaid expansion has been associated with improvements in cancer-related health outcomes, including improved survival rates. However, limitations and gaps in the current research on the impact of Medicaid expansion on patients with cancer exist, including a lack of long-term data on health outcomes. Additionally, further research is needed to better understand the mechanisms through which Medicaid expansion impacts cancer care.
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Affiliation(s)
- Alexandra Hotca
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Julie R Bloom
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Juliana Runnels
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Lucas Resende Salgado
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Daniel R Cherry
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Kristin Hsieh
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Kunal K Sindhu
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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Barnes JM, Neff C, Han X, Kruchko C, Barnholtz-Sloan JS, Ostrom QT, Johnson KJ. The association of Medicaid expansion and pediatric cancer overall survival. J Natl Cancer Inst 2023; 115:749-752. [PMID: 36782354 PMCID: PMC10248835 DOI: 10.1093/jnci/djad024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 01/04/2023] [Accepted: 01/28/2023] [Indexed: 02/15/2023] Open
Abstract
Medicaid eligibility expansion, though not directly applicable to children, has been associated with improved access to care in children with cancer, but associations with overall survival are unknown. Data for children ages 0 to 14 years diagnosed with cancer from 2011 to 2018 were queried from central cancer registries data covering cancer diagnoses from 40 states as part of the Centers for Disease Control and Prevention's National Program of Cancer Registries. Difference-in-differences analyses were used to compare changes in 2-year survival from 2011-2013 to 2015-2018 in Medicaid expansion relative to nonexpansion states. In adjusted analyses, there was a 1.50 percentage point (95% confidence interval = 0.37 to 2.64) increase in 2-year overall survival after 2014 in expansion relative to nonexpansion states, particularly for those living in the lowest county income quartile (difference-in-differences = 5.12 percentage point, 95% confidence interval = 2.59 to 7.65). Medicaid expansion may improve cancer outcomes for children with cancer.
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Affiliation(s)
- Justin M Barnes
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Corey Neff
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC, USA
- Central Brain Tumor Registry of the United States, Hinsdale, IL, USA
| | - Xuesong Han
- Surveillance & Health Equity Science, American Cancer Society, Atlanta, GA, USA
| | - Carol Kruchko
- Central Brain Tumor Registry of the United States, Hinsdale, IL, USA
| | - Jill S Barnholtz-Sloan
- Central Brain Tumor Registry of the United States, Hinsdale, IL, USA
- Center for Biomedical Informatics & Information Technology and Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Quinn T Ostrom
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC, USA
- Central Brain Tumor Registry of the United States, Hinsdale, IL, USA
- The Preston Robert Tisch Brain Tumor Center, Duke University School of Medicine, Durham, NC, USA
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
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15
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Barnes JM, Graboyes EM, Adjei Boakye E, Schootman M, Chino JP, Moss HA, Mowery YM, Osazuwa-Peters N. Insurance Coverage and Forgoing Medical Appointments Because of Cost Among Cancer Survivors After 2016. JCO Oncol Pract 2023; 19:e589-e599. [PMID: 36649493 PMCID: PMC10530391 DOI: 10.1200/op.22.00587] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/19/2022] [Accepted: 12/01/2022] [Indexed: 01/19/2023] Open
Abstract
PURPOSE The uninsured rate began rising after 2016, which some have attributed to health policies undermining aspects of the Affordable Care Act. Our primary objectives were to assess the changes in insurance coverage and forgoing medical care because of cost in cancer survivors from pre-enactment (2016) through postenactment of those policies (2019) and determine whether there were subgroups that were disproportionately affected. METHODS The 2016-2019 Behavioral Risk Factor Surveillance System surveys were queried for 18- to 64-year-old cancer survivors. Survey-weighted logistic regression was used to assess temporal changes in (1) insurance coverage and (2) forgoing medical appointments because of cost in the preceding 12 months. RESULTS A total of 62,669 cancer survivors were identified. The percentage of insured cancer survivors decreased from 92.4% in 2016 to 90.4% in 2019 (odds ratio for change in insurance coverage or affordability per one-year increase [ORyear], 0.92; 95% CI, 0.86 to 0.98; P = .01), translating to 161,000 fewer cancer survivors in the United States with insurance coverage. There were decreases in employer-sponsored insurance coverage (ORyear, 0.89) but increases in Medicaid coverage (ORyear, 1.17) from 2016 to 2019. Forgoing medical appointments because of cost increased from 17.9% in 2016 to 20.0% in 2019 (ORyear, 1.05; 95% CI, 1.01 to 1.1; P = .025), affecting an estimated 169,000 cancer survivors. The greatest changes were observed among individuals with low income, particularly those residing in nonexpansion states. CONCLUSION Between 2016 and 2019, there were 161,000 fewer cancer survivors in the United States with insurance coverage, and 169,000 forwent medical care because of cost.
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Affiliation(s)
- Justin M. Barnes
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, MO
| | - Evan M. Graboyes
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Eric Adjei Boakye
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI
- Department of Otolaryngology Head and Neck Surgery, Henry Ford Health System, Detroit, MI
| | - Mario Schootman
- Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Junzo P. Chino
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC
- Duke Cancer Institute, Durham, NC
| | - Haley A. Moss
- Duke Cancer Institute, Durham, NC
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Yvonne M. Mowery
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC
- Duke Cancer Institute, Durham, NC
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, NC
| | - Nosayaba Osazuwa-Peters
- Duke Cancer Institute, Durham, NC
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, NC
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
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16
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Laughlin AI, Li T, Yu Q, Wu XC, Yi Y, Hsieh MC, Havron W, Shoup M, Chu QD. Impact of Medicaid Expansion on Breast Cancer Diagnosis and Treatment in Southern States. J Am Coll Surg 2023; 236:838-845. [PMID: 36722711 DOI: 10.1097/xcs.0000000000000550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Medicaid expansion impacted patients when assessed at a national level. However, of the 32 states that expanded Medicaid, only three were Southern states. Whether results apply to Southern states that share similar geopolitical perspectives remains elusive. We aimed to assess the impact of Medicaid expansion on breast cancer diagnosis and treatment in 8 Southern states in the US. STUDY DESIGN We identified uninsured or Medicaid patients (age 40 to 64 years) diagnosed with invasive breast cancer from 2011 to 2018 in Southern states from the North American Association of Central Cancer Registries-Cancer in North America Research Dataset. Medicaid-expanded states ([MES], Louisiana, Kentucky, Arkansas) were compared with non-MES ([NMES], Tennessee, Alabama, Mississippi, Texas, Oklahoma) using multivariate logistic regression and differences-in-differences analyses during pre- and postexpansion periods; p < 0.05 was considered statistically significant. RESULTS Among 21,974 patients, patients in MES had increased odds of Medicaid insurance by 43% (odds ratio 1.43, p < 0.01) and decreased odds of distant-stage disease by 7% (odds ratio 0.93, p = 0.03). After Medicaid expansion, Medicaid patients increased by 10.6% in MES (Arkansas, Kentucky), in contrast to a 1.3% decrease in NMES (differences-in-differences 11.9%, p < 0. 0001, adjusting for age, race/ethnicity, rural-urban status, and poverty status). MES (Arkansas, Kentucky) had 2.3% fewer patients diagnosed with distant-stage disease compared with a 0.5% increase in NMES (differences-in-differences 2.8%, p = 0.01, after adjustment). Patients diagnosed in MES had higher odds of receiving treatment (odds ratio 2.27, p = 0.03). CONCLUSIONS Unlike NMES, MES experienced increased Medicaid insured, increased treatment, and decreased distant-stage disease at diagnosis. Medicaid expansion in the South leads to earlier and more comprehensive treatment of breast cancer.
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Affiliation(s)
- Amy I Laughlin
- From the Orlando Health Cancer Institute, Orlando, FL (Laughlin, Havron, Shoup, Chu)
| | - Tingting Li
- Louisiana Tumor Registry and Epidemiology Program, School of Public Health, Louisiana State University Health Sciences Center - New Orleans, New Orleans, LA (Li, Yu, Wu, Yi, Hsieh)
- School of Public Health, Louisiana State University Health Sciences Center - New Orleans, New Orleans, LA (Li, Yu, Wu, Yi, Hsieh)
| | - Qingzhao Yu
- Louisiana Tumor Registry and Epidemiology Program, School of Public Health, Louisiana State University Health Sciences Center - New Orleans, New Orleans, LA (Li, Yu, Wu, Yi, Hsieh)
- School of Public Health, Louisiana State University Health Sciences Center - New Orleans, New Orleans, LA (Li, Yu, Wu, Yi, Hsieh)
| | - Xiao-Cheng Wu
- Louisiana Tumor Registry and Epidemiology Program, School of Public Health, Louisiana State University Health Sciences Center - New Orleans, New Orleans, LA (Li, Yu, Wu, Yi, Hsieh)
- School of Public Health, Louisiana State University Health Sciences Center - New Orleans, New Orleans, LA (Li, Yu, Wu, Yi, Hsieh)
| | - Yong Yi
- Louisiana Tumor Registry and Epidemiology Program, School of Public Health, Louisiana State University Health Sciences Center - New Orleans, New Orleans, LA (Li, Yu, Wu, Yi, Hsieh)
- School of Public Health, Louisiana State University Health Sciences Center - New Orleans, New Orleans, LA (Li, Yu, Wu, Yi, Hsieh)
| | - Mei-Chin Hsieh
- Louisiana Tumor Registry and Epidemiology Program, School of Public Health, Louisiana State University Health Sciences Center - New Orleans, New Orleans, LA (Li, Yu, Wu, Yi, Hsieh)
- School of Public Health, Louisiana State University Health Sciences Center - New Orleans, New Orleans, LA (Li, Yu, Wu, Yi, Hsieh)
| | - William Havron
- From the Orlando Health Cancer Institute, Orlando, FL (Laughlin, Havron, Shoup, Chu)
| | - Margo Shoup
- From the Orlando Health Cancer Institute, Orlando, FL (Laughlin, Havron, Shoup, Chu)
| | - Quyen D Chu
- From the Orlando Health Cancer Institute, Orlando, FL (Laughlin, Havron, Shoup, Chu)
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17
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Ji X, Shi KS, Mertens AC, Zhao J, Yabroff KR, Castellino SM, Han X. Survival in Young Adults With Cancer Is Associated With Medicaid Expansion Through the Affordable Care Act. J Clin Oncol 2023; 41:1909-1920. [PMID: 36525612 PMCID: PMC10082236 DOI: 10.1200/jco.22.01742] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 10/26/2022] [Accepted: 11/08/2022] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- Xu Ji
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
- Aflac Cancer & Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA
| | - Kewei Sylvia Shi
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA
| | - Ann C. Mertens
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
- Aflac Cancer & Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA
| | - Jingxuan Zhao
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA
| | - K. Robin Yabroff
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA
| | - Sharon M. Castellino
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
- Aflac Cancer & Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA
| | - Xuesong Han
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA
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18
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Huepenbecker SP, Fu S, Sun CC, Zhao H, Primm KM, Giordano SH, Meyer LA. Medicaid Expansion and Postoperative Mortality in Women with Gynecologic Cancer: A Difference-in-Difference Analysis. Ann Surg Oncol 2023; 30:1508-1519. [PMID: 36310311 PMCID: PMC10466211 DOI: 10.1245/s10434-022-12663-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/28/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND The association between Medicaid expansion and postoperative mortality after surgery for gynecologic cancer is unknown. Our objective was to compare 30- and 90-day postoperative mortality after gynecologic cancer surgery before and after 2014 in states that did and did not expand Medicaid. METHODS We searched the National Cancer Database for women aged 40-64 years old between 2010 and 2016 who underwent surgery for a primary gynecologic malignancy. We used pre/post and quasi-experimental difference-in-difference (DID) multivariable logistic regressions to evaluate mortality pre-2014 (2010-2013) and post-2014 (2014-2016) for states that did and did not expand Medicaid in January 2014. We completed univariable logistic regressions for covariates of interest. RESULTS Among 169,731 women, 30-day postoperative mortality in expansion states after 2014 significantly decreased for endometrial cancer (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.26-0.67) and ovarian cancer (OR 0.67, 95% CI 0.46-0.99) and increased for cervical cancer (OR 3.82, 95% CI 1.12-13.01). Compared with non-expansion states, expansion states had improved 30-day postoperative mortality for endometrial cancer after 2014 (DID OR 0.54, 95% CI 0.31-0.96). Univariable analysis demonstrated improved 30-day postoperative mortality for Black women with endometrial cancer in expansion states (DID OR 0.22, 95% CI 0.05-0.95). There was improved 90-day postoperative mortality for endometrial cancer in expansion states (OR 0.66, 95% CI 0.50-0.85), and improved 90-day postoperative mortality for Midwestern women with ovarian cancer in expansion states on univariable analysis (DID OR 0.48, 95% CI 0.26-0.91). CONCLUSIONS State Medicaid legislation was associated with improved postoperative survival in women with endometrial cancer and subgroups of women with endometrial and ovarian cancer.
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Affiliation(s)
- Sarah P Huepenbecker
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1362, Houston, TX, 77030, USA
| | - Shuangshuang Fu
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Becton, Dickinson and Company, Franklin Lakes, NJ, USA
| | - Charlotte C Sun
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1362, Houston, TX, 77030, USA
| | - Hui Zhao
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kristin M Primm
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sharon H Giordano
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1362, Houston, TX, 77030, USA.
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Chapman-Davis E, Webster EM, Ahsan MD, Holcomb K. Expanding Medicaid Improves Outcomes in Gynecologic Malignancies, But is it Enough? Ann Surg Oncol 2023; 30:1290-1292. [PMID: 36348204 DOI: 10.1245/s10434-022-12766-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 10/24/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Eloise Chapman-Davis
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY, USA.
| | - Emily M Webster
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY, USA
| | - Muhammad Danyal Ahsan
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY, USA
| | - Kevin Holcomb
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY, USA
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Kazzi B, Chino F, Kazzi B, Jain B, Tian S, Paguio JA, Yao JS, Muralidhar V, Mahal BA, Nguyen PL, Sanford NN, Dee EC. Shared burden: the association between cancer diagnosis, financial toxicity, and healthcare cost-related coping mechanisms by family members of non-elderly patients in the USA. Support Care Cancer 2022; 30:8905-8917. [PMID: 35877007 DOI: 10.1007/s00520-022-07234-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 06/14/2022] [Indexed: 01/05/2023]
Abstract
PURPOSE There has been little research on the healthcare cost-related coping mechanisms of families of patients with cancer. Therefore, we assessed the association between a cancer diagnosis and the healthcare cost-related coping mechanisms of participant family members through their decision to forego or delay seeking medical care, one of the manifestations of financial toxicity. METHODS Using data from the National Health Interview Survey (NHIS) between 2000 and 2018, sample weight-adjusted prevalence was calculated and multivariable logistic regressions defined adjusted odds ratios (aORs) for participant family members who needed but did not get medical care or who delayed seeking medical care due to cost in the past 12 months, adjusting for relevant sociodemographic covariates, including participant history of cancer (yes vs. no) and participant age (18-45 vs. 46-64 years old). The analysis of family members foregoing or delaying medical care was repeated using a cancer diagnosis * age interaction term. RESULTS Participants with cancer were more likely than those without a history of cancer to report family members delaying (19.63% vs. 16.31%, P < 0.001) or foregoing (14.53% vs. 12.35%, P = 0.001) medical care. Participants with cancer in the 18 to 45 years old age range were more likely to report family members delaying (pinteraction = 0.028) or foregoing (pinteraction < 0.001) medical care. Other factors associated with cost-related coping mechanisms undertaken by the participants' family members included female sex, non-married status, poorer health status, lack of health insurance coverage, and lower household income. CONCLUSION A cancer diagnosis may be associated with familial healthcare cost-related coping mechanisms, one of the manifestations of financial toxicity. This is seen through delayed/omitted medical care of family members of people with a history of cancer, an association that may be stronger among young adult cancer survivors. These findings underscore the need to further explore how financial toxicity associated with a cancer diagnosis can affect patients' family members and to design interventions to mitigate healthcare cost-related coping mechanisms.
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Affiliation(s)
- Bahaa Kazzi
- Department of Biology, Emory University, Atlanta, GA, USA
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 02446, USA
| | - Brigitte Kazzi
- Department of Internal Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Bhav Jain
- Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Sibo Tian
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, USA
| | - Joseph A Paguio
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - J Seth Yao
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | | | - Brandon A Mahal
- Department of Radiation Oncology, University of Miami/Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nina N Sanford
- Department of Radiation Oncology, University of Texas Southwestern, 2280 Inwood Road, Dallas, TX, 75235, USA.
| | - Edward Christopher Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 02446, USA.
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Dee EC, Pierce LJ, Winkfield KM, Lam MB. In pursuit of equity in cancer care: moving beyond the Affordable Care Act. Cancer 2022; 128:3278-3283. [PMID: 35818772 DOI: 10.1002/cncr.34346] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 04/25/2022] [Accepted: 05/19/2022] [Indexed: 11/10/2022]
Abstract
Although Medicaid Expansion under the Patient Protection and Affordable Care Act (ACA) has been associated with many improvements for patients with cancer, Snyder et al. provide evidence demonstrating the persistence of racial disparities in cancer. This Editorial describes why insurance coverage alone does not ensure access to health care, highlights various manifestations of structural racism that constitute barriers to access beyond the direct costs of care, and calls for not just equality, but equity, in cancer care.
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Affiliation(s)
- Edward Christopher Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Lori J Pierce
- Department of Radiation Oncology, Rogel Comprehensive Cancer Center, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Karen M Winkfield
- Meharry-Vanderbilt Alliance, Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Miranda B Lam
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, USA
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22
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Shih YCT, Owsley KM, Nicholas LH, Yabroff KR, Bradley CJ. Cancer's Lasting Financial Burden: Evidence From a Longitudinal Assessment. J Natl Cancer Inst 2022; 114:1020-1028. [PMID: 35325197 PMCID: PMC9275752 DOI: 10.1093/jnci/djac064] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/04/2022] [Accepted: 03/16/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The purpose of this study was to conduct a longitudinal analysis of out-of-pocket expenditure (OOPE) trajectories for the assessment of cancer's lasting financial impact. METHODS We identified newly diagnosed cancer patients and constructed matched control group of noncancer participants from the 2002-2018 Health and Retirement Study. Outcomes included monthly OOPE for prescription drugs (RX-OOPE_MONTHLY) and OOPE for medical services other than drugs in the past 2 years (non-RX-OOPE_2YR), consumer debt, and new individual retirement account (IRA) withdrawals. Generalized linear models were used to compare OOPEs between cancer and matched control groups. Logistic regressions were used to compare household-level consumer debt or early IRA withdrawal. Subgroup analysis stratified patients by age, health status, and household income, with the low-income group stratified by Medicaid coverage. All statistical tests were 2-sided. RESULTS The study cohort included 2022 cancer patients and 10 110 participants in the matched noncancer control group. Mean non-RX-OOPE_2YR of cancer patients was similar to that of participants in the matched control group before diagnosis but statistically significantly higher at diagnosis ($1157, P < .001), 2 ($511, P < .001) years, 4 ($360, P = .006) years, and 6 ($430, P = .01) years after diagnosis. A similar pattern was observed in RX-OOPE_MONTHLY. A statistically significantly higher proportion of cancer patients incurred consumer debt at diagnosis (34.5% vs 29.9%; P < .001) and 2 years after (32.5% vs 28.2%; P = .002). There was no statistically significant difference in new IRA withdrawals. Patients experienced lasting financial consequences following cancer diagnosis that were most pronounced among patients aged 65 years and older, in good-to-excellent health at baseline, and with low income, but without Medicaid coverage. CONCLUSIONS Policies to reduce costs and expand insurance coverage options while reducing cost-sharing are needed.
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Affiliation(s)
- Ya-Chen Tina Shih
- Section of Cancer Economics and Policy, Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kelsey M Owsley
- Department of Health Systems, Management, and Policy, University of Colorado Comprehensive Cancer Center and Colorado School of Public Health, Aurora, CO, USA
| | - Lauren Hersch Nicholas
- Department of Health Systems, Management, and Policy, University of Colorado Comprehensive Cancer Center and Colorado School of Public Health, Aurora, CO, USA
| | - K Robin Yabroff
- Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, GA, USA
| | - Cathy J Bradley
- Department of Health Systems, Management, and Policy, University of Colorado Comprehensive Cancer Center and Colorado School of Public Health, Aurora, CO, USA
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23
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Pesko MF. How Data Security Concerns Can Hinder Natural Experiment Research: Background and Potential Solutions. J Natl Cancer Inst Monogr 2022; 2022:89-94. [PMID: 35788379 PMCID: PMC9255918 DOI: 10.1093/jncimonographs/lgac007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 02/24/2022] [Indexed: 11/12/2022] Open
Abstract
Health economists conducting cancer-related research often use geocoded data to analyze natural experiments generated by policy changes. These natural experiments can provide causal interpretation under certain conditions. Despite public health benefit of this rigorous natural experiment methodology, data providers are often reluctant to provide geocoded data because of confidentiality concerns. This paper provides an example of the value of natural experiments from e-cigarette research and shows how this research was hindered by security concerns. Although the tension between data access and security will not be resolved overnight, this paper offers 3 recommendations: 1) provide public access to aggregated data at area levels (eg, state) where possible; 2) approve projects with enough time to allow for publication in journals with lengthy peer-review times; and 3) improve communication and transparency between data providers and the research community. The Foundations for Evidence Based Policymaking Act of 2018 also presents a unique opportunity for improving the ability of researchers to use geocoded data for natural experiment research without compromising data security.
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Affiliation(s)
- Michael F Pesko
- Department of Economics, Andrew Young School of Policy Studies, Georgia State University, Atlanta, GA, USA.,Institute of Labor Economics, Bonn, Germany
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24
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Patel H, Barnes J, Osazuwa-Peters N, Bierut LJ. Association of State Medicaid Expansion Status With Rates of Suicide Among US Adults. JAMA Netw Open 2022; 5:e2217228. [PMID: 35704315 PMCID: PMC9201676 DOI: 10.1001/jamanetworkopen.2022.17228] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
IMPORTANCE In the US, suicide is the 10th leading cause of death and a serious mental health emergency. National programs that address suicide list access to mental health care as key in prevention, and more large-scale policies are needed to improve access to mental health care and address this crisis. The Patient Protection and Affordable Care Act (ACA) Medicaid Expansion Program was implemented in several states with the goal of increasing access to the health care system. OBJECTIVE To compare changes in suicide rates in states that expanded Medicaid under the ACA vs states that did not. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study, state-level mortality rates were obtained from the National Center for Health Statistics for US individuals aged 20 to 64 years from January 1, 2000, to December 31, 2018. Data analysis was performed from April 18, 2021, to April 15, 2022. EXPOSURES Changes in suicide mortality rates among nonelderly adults before and after Medicaid expansion in expansion and nonexpansion states were compared using adjusted difference-in-differences analyses via hierarchical bayesian linear regression. MAIN OUTCOMES AND MEASURES Suicide rates using death by suicide as the primary measure. RESULTS Of the total population at risk for suicide, 50.4% were female, 13.3% were Black, 79.5% were White, and 7.2% were of other races. The analytic data set contained suicide mortality data for 2907 state-age-year units covering the general US population. A total of 553 912 deaths by suicide occurred during the study period, with most occurring in White (496 219 [89.6%]) and male (429 580 [77.6%]) individuals. There were smaller increases in the suicide rate after 2014 in Medicaid expansion (2.56 per 100 000 increase) compared with nonexpansion states (3.10 per 100 000 increase). In adjusted difference-in-differences analysis, a significant decrease of -0.40 (95% credible interval, -0.66 to -0.14) suicides per 100 000 individuals was found, translating to 1818 suicides that were averted in 2015 to 2018. CONCLUSIONS AND RELEVANCE In this cross-sectional study, although suicide rates increased in both groups, blunting of these rates occurred among nonelderly adults in the Medicaid expansion states compared with nonexpansion states. Because this difference may be linked to increased access to mental health care, policy makers should consider suicide prevention as a benefit of expanding access to health care.
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Affiliation(s)
- Hetal Patel
- Department of Psychiatry, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Justin Barnes
- Department of Radiation Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Nosayaba Osazuwa-Peters
- Deputy Editor, Diversity, Equity, and Inclusion, JAMA Otolaryngology–Head and Neck Surgery
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Laura Jean Bierut
- Department of Psychiatry, Washington University School of Medicine in St Louis, St Louis, Missouri
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