American Society of Clinical Oncology policy statement on medicaid reform

Enhancing Health Equity Through Cancer Health Economics Research

Cancer displays some of the largest health-equity concerns of all diseases. This paper draws attention to how health economics research can assess strategies to reduce or even eliminate health disparities and provides pivotal examples of existing research as well as areas for future contributions. The paper also highlights critical data limitations that currently restrain the impact health economics research could have. We then explore new areas of inquiry where economic research is sparse but could have an important impact on health equity, particularly in topics involving Medicare and Medicaid policies that expand reimbursement and generosity of coverage. Health economics studies are notably absent from policies and practices surrounding clinical trials, representing an opportunity for future research. We urge health economics researchers to consider experiments, interventions, and assessments through primary data collection; we further encourage the formulation of multidisciplinary teams to ensure that health economics skills are well melded with other areas of expertise. These teams are needed to maximize novelty and rigor of evidence. As policies are promulgated to address disparities in cancer, involvement of economics in a multidisciplinary context can help ensure that these policies do not have unintended impacts that may deepen inequities.

Health Insurance Coverage and Survival Outcomes among Nasopharyngeal Carcinoma Patients: A SEER Retrospective Analysis

Objectives Insurance coverage plays a critical role in head and neck cancer care. This retrospective study examines how insurance coverage affects nasopharyngeal carcinoma (NPC) survival in the United States using the Surveillance, Epidemiology, and End Results (SEER) program database.

Design, Setting, and Participants A total of 2,278 patients aged 20 to 64 years according to the International Classification of Diseases for Oncology (ICD-O) codes C11.0–C11.9 and ICD-O histology codes 8070–8078 and 8080–8083 between 2007 and 2016 were included and grouped into privately insured, Medicaid, and uninsured groups. Log-rank test and multivariable Cox's proportional hazard model were performed.

Main Outcome Measures Tumor stage, age, sex, race, marital status, disease stage, year of diagnosis, median household county income, and disease-specific survival outcomes including cause of death were analyzed.

Results Across all tumor stages, privately insured patients had a 59.0% lower mortality risk than uninsured patients (hazard ratio [HR]: 0.410, 95% confidence interval [CI]: [0.320, 0.526], p < 0.01). Medicaid patients were also estimated to have 19.0% lower mortality than uninsured patients (HR: 0.810, 95% CI: [0.626, 1.048], p = 0.108). Privately insured patients with regional and distant NPC had significantly better survival outcomes compared with uninsured individuals. Localized tumors did not show any association between survival and type of insurance coverage.

Conclusion Privately insured individuals had significantly better survival outcomes than uninsured or Medicaid patients, a trend that was preserved after accounting for tumor grade, demographic and clinicopathologic factors. These results underscore the difference in survival outcomes when comparing privately insured to Medicaid/uninsured populations and warrant further investigation in efforts for health care reform.

Outcomes of Lymphoma Among American Adolescent and Young Adult Patients Varied by Health Insurance-A SEER-based Study

INTRODUCTION

Impacts of health insurance status on survival outcomes among adolescent and young adult (AYA, 15 to 39 years of age) patients with lymphoma in the United States are insufficiently known. This study aimed to clarify associations between health insurance status and overall survival (OS) estimates in this population.

MATERIALS AND METHODS

We examined 18 Surveillance, Epidemiology, and End Results registries in the United States and analyzed American AYA patients with lymphoma diagnosed during January 2007 and December 2016. Health insurance status was categorized, and Kaplan-Meier and multifactor Cox regressions were adopted using hazard ratio and 95% confidence interval. Probable baseline confounding was modulated by multiple propensity score.

RESULTS

A total of 21,149 patients were considered; ~28% were 18 to 25 years old, and 63.5% and 7.5% had private and no insurance, respectively. Private insurance rates increased in the 18 to 25 age group (60.1% to 6.1%, P<0.001) following the 2010 Patient Protection and Affordable Care Act (ACA), and lymphoma survival rates improved slightly 1 to 5 years postdiagnosis. Five-year OS rates decreased with age (93.9%, 90.4%, and 87.0% at 15 to 17, 18 to 25, and 26 to 39, respectively) and differed among insurance conditions (81.7%, 79.2%, 89.2%, and 92.0% for uninsured, Medicaid, insured, and insured/no specifics, respectively). Risk of death was significantly higher for those with Medicaid or no insurance than for those with private insurance in multiple propensity score-adjusted models (hazard ratio [95% confidence interval]=1.07 [1.03-1.12]), independent of stage at diagnosis.

CONCLUSIONS

No or insufficient insurance was linked to poor OS in our sample in exposure-outcome association analysis. Insurance coverage and health care availability may enhance disparate outcomes of AYAs with cancer. The ACA has improved insurance coverage and survival rates for out sample. Nevertheless, strategies are needed to identify causality and eliminate disparities.

Understanding the Implications of Medicaid Expansion for Cancer Care in the US: A Review

Importance

Insurance status has been linked to important differences in cancer treatment and outcomes in the US. With more than 15 million individuals gaining health insurance through Medicaid expansion, there is an increasing need to understand the implications of this policy within the US cancer population. This review provides an overview of the fundamental principles and nuances of Medicaid expansion, as well as the implications for cancer care.

Observations

The Patient Protection and Affordable Care Act presented states with an option to expand Medicaid coverage by broadening the eligibility criteria (eg, raising the eligible income level). During the past 10 years, Medicaid expansion has been credited with a 30% reduction in the population of uninsured individuals in the US. Such a significant change in the insurance profile could have important implications for the 1.7 million patients diagnosed with cancer each year, the oncology teams that care for them, and policy makers. However, several factors may complicate efforts to characterize the effect of Medicaid expansion on the US cancer population. Most notably, there is considerable variation among states in terms of whether Medicaid expansion took place, when expansion occurred, eligibility criteria for Medicaid, and coverage types that Medicaid provides. In addition, economic and health policy factors may be intertwined with factors associated with Medicaid expansion. Finally, variability in the manner in which cancer care has been captured and depicted in large databases could affect the interpretation of findings associated with expansion.

Conclusions and Relevance

The expansion of Medicaid was a historic public policy initiative. To fully leverage this policy to improve oncological care and to maximize learning for subsequent policies, it is critical to understand the effect of Medicaid expansion. This review aims to better prepare investigators and their audiences to fully understand the implications of this important health policy initiative.

Survival Disparities in Multiple Myeloma by Health Insurance Status among US Non-Elderly Adults: A SEER-Based Comparative Analysis

BACKGROUND/AIM

The impacts of health insurance status on survival outcomes in multiple myeloma (MM) have not been addressed in depth. The present study was conducted to identify definite relationships of cancer-specific survival (CSS) and overall survival (OS) with health insurance status in MM patients.

METHODS

MM patients aged 18-64 years and with complete insurance records between January 1, 2007, and December 31, 2016, were identified from 18 Surveillance, Epidemiology, and End Results (SEER) Database registries. Health insurance condition was categorized as uninsured, any Medicaid, insured, and insured (no specifics). Relationships of health insurance condition with OS/CSS were identified through Kaplan-Meier, and uni-/multivariate Cox regressions using the hazard ratio and 95% confidence interval. Potential baseline confounding was adjusted using multiple propensity score (mPS).

RESULTS

Totally 17,981 patients were included, including 68.3% with private insurance and only 4.9% with uninsurance. Log-rank test uncovered significant difference between health insurance status and OS/CSS among MM patients. Patients with non-insurance or Medicaid coverage in comparison with private insurance tended to present poorer OS/CSS both in multivariate Cox regression and in mPS-adjusted model (non-insurance vs. private insurance [OS/CSS]: 1.33 [1.20-1.48]/1.13 [1.00-1.28] and 1.45 [1.25-1.69]/1.18 [1.04-1.33], respectively; Medicaid coverage vs. private insurance [OS/CSS]: 1.67 [1.56-1.78]/1.25 [1.16-1.36] and 1.76 [1.62-1.90]/1.23 [1.13-1.35], respectively).

CONCLUSIONS

Our observational study of exposure-outcome associations suggests that insufficient or no insurance is moderately linked with OS among MM patients aged 18-64 years. Wide insurance coverage and health-care availability may strengthen some disparate outcomes. In the future, prospective cohort research is needed to further clarify concrete risks with insurance type, owing to the lack of definite division of insurance data in SEER.

A Qualitative Analysis of State Medicaid Coverage Benefits for Allogeneic Hematopoietic Cell Transplantation (alloHCT) for Patients with Sickle Cell Disease (SCD)

Sickle cell disease (SCD) is the most common inherited hemoglobin disorder, affecting approximately 100,000 people in the United States. Allogeneic hematopoietic cell transplantation (alloHCT), also known as bone marrow transplant (BMT), is currently the only established curative option for SCD. However, alloHCT is an optional benefit under Medicaid. This study of alloHCT coverage for patients with SCD aims to understand the scope of state Medicaid coverage benefits and BMT financial coordinators' experience working with their state Medicaid programs. States estimated to have more than 50 newborns diagnosed with SCD in 2016 and at least one active BMT Clinical Trials Network (1503 [STRIDE 2], NCT02766465) transplant center (TC) were eligible to participate in this study. Qualitative, semi-structured interviews 30 to 60 minutes in length were conducted with BMT financial coordinators via telephone between May and October 2019. A total of 10 BMT financial coordinators from 10 TCs representing eight states (Florida, Georgia, Illinois, Michigan, New York, Pennsylvania, Texas, and Virginia) participated in the semi-structured interviews. Coordinators in all of the included states reported that alloHCT in children with SCD with a human leukocyte antigen-matched sibling donor was covered by their state Medicaid programs. However, only two states (Florida and Texas) had legislative policies mandating coverage of routine medical costs for patients in clinical trials. TCs in two states (Illinois and Pennsylvania) reported accepting out-of-state Medicaid insurance, but only one state (Michigan) covered both travel and lodging for the patient and one caregiver. Four themes emerged when coordinators were asked about their perspectives and experiences working with their corresponding state Medicaid programs: (1) state Medicaid eligibility criteria based on disability were perceived as being restrictive, and Medicaid reimbursement rates were reported to be low; (2) Medicaid fee-for-service plans were perceived as being more comprehensive and easier to navigate compared to comprehensive managed care (CMC) plans; (3) there is a need to address caregiver and financial assistance beyond the health care costs; and (4) completing the insurance authorization process leading up to alloHCT is critical, including peer-to-peer reviews. There is limited legislative policy to help ensure access to clinical trials and provide out-of-state benefits and travel and lodging for Medicaid enrollees with SCD. These data provide insight into potential areas that could influence changes in policy to enhance access to curative therapy for SCD.

American Society of Clinical Oncology Road to Recovery Report: Learning From the COVID-19 Experience to Improve Clinical Research and Cancer Care

This report presents the American Society of Clinical Oncology's (ASCO's) evaluation of the adaptations in care delivery, research operations, and regulatory oversight made in response to the coronavirus pandemic and presents recommendations for moving forward as the pandemic recedes. ASCO organized its recommendations for clinical research around five goals to ensure lessons learned from the COVID-19 experience are used to craft a more equitable, accessible, and efficient clinical research system that protects patient safety, ensures scientific integrity, and maintains data quality. The specific goals are: (1) ensure that clinical research is accessible, affordable, and equitable; (2) design more pragmatic and efficient clinical trials; (3) minimize administrative and regulatory burdens on research sites; (4) recruit, retain, and support a well-trained clinical research workforce; and (5) promote appropriate oversight and review of clinical trial conduct and results. Similarly, ASCO also organized its recommendations regarding cancer care delivery around five goals: (1) promote and protect equitable access to high-quality cancer care; (2) support safe delivery of high-quality cancer care; (3) advance policies to ensure oncology providers have sufficient resources to provide high-quality patient care; (4) recognize and address threats to clinician, provider, and patient well-being; and (5) improve patient access to high-quality cancer care via telemedicine. ASCO will work at all levels to advance the recommendations made in this report.

Association of Medicaid Insurance With Survival Among Patients With Small Cell Lung Cancer

IMPORTANCE

Small cell lung cancer (SCLC) is an aggressive neoplasm requiring rapid access to subspecialized multidisciplinary care. For this reason, insurance coverage such as Medicaid may be associated with oncologic outcomes in this disproportionately economically vulnerable population. With Medicaid expansion under the Affordable Care Act, it is important to understand outcomes associated with Medicaid coverage among patients with SCLC.

OBJECTIVE

To determine the association of Medicaid coverage with survival compared with other insurance statuses.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included adult patients with limited-stage (LS) and extensive-stage (ES) SCLC in the US National Cancer Database from 2004 to 2013. Data were analyzed in January 2019.

MAIN OUTCOMES AND MEASURES

Patients were analyzed with respect to insurance status. Associations of insurance status with survival were interrogated with univariate analyses, multivariable analyses, and propensity score matching.

RESULTS

A total of 181 784 patients with SCLC (93 131 [51.2%] female; median [interquartile range] age; 67 [60-75] years for patients with LS-SCLC and 68 [60-75] years for patients with ES-SCLC) were identified, of whom 70 247 (38.6%) had LS-SCLC and 109 479 (60.2%) had ES-SCLC. On univariate analyses of patients with LS-SCLC, Medicaid coverage was not associated with a survival advantage compared with being uninsured (hazard ratio, 1.02; 95% CI, 0.96-1.08; P = .49). Likewise, on multivariable analyses of patients with ES-SCLC, compared with being uninsured, Medicaid coverage was not associated with a survival advantage (hazard ratio, 1.00; 95% CI, 0.96-1.03; P = .78). After propensity score matching, median survival was similar between the uninsured and Medicaid groups both among patients with LS-SCLC (14.4 vs 14.1 months; hazard ratio, 1.05; 95% CI, 0.98-1.12; P = .17) and those with ES-SCLC (6.3 vs 6.4 months; hazard ratio, 1.00; 95% CI, 0.96-1.04; P = .92).

CONCLUSIONS AND RELEVANCE

Despite of billions of dollars in annual federal and state spending, Medicaid was not associated with improved survival in patients with SCLC compared with being uninsured in the US National Cancer Database. These findings suggest that there are substantial outcome inequalities for SCLC relevant to the policy debate on the Medicaid expansion under the Affordable Care Act.

NSCLC patient "migration" for treatment: A retrospective analysis of patient characteristics, travel patterns, and survival differences

PURPOSE

Every year a significant population exists of those diagnosed with nonsmall cell lung cancer (NSCLC) who do not receive initial treatment upon diagnosis and then "migrate" to additional hospital before ultimately getting treatment. Migration to different hospitals may play a role in the decision to treat or not-to-treat, and we aimed to evaluate the potential factors that lead to treatment.

METHODS

A retrospective review of 6212 patients with NSCLC from 29 Kentucky hospital registries from 2012 to 2014 was performed. Variables collected included hospital accreditation status, age at diagnosis, stage, overall survival (OS), and insurance status. Hospital records were matched to Kentucky Cancer Registry records to determine the number of hospitals visited for treatment.

RESULTS

Most patients were treated at their initial hospital (73%). Of the remaining patients, 36% migrated to a different hospital where most received treatment (93%). Migrating to another hospital was associated with Stage I-III disease, younger age (66.4 vs 72.2 years), and longer OS (561 vs 157 days). Notably, migration was also associated with private insurance status and missing treatment modalities at the initial hospital. Treatment after migrating was associated with Stage I-II disease, younger age (65.8 vs 72.8 years), and longer OS (595 vs 153 days). After adjusting for confounders, treated migrating patients lived longer than initially treated patients (591 vs 505 days), especially among those with stage III (563 vs 495 days) and IV (379 vs 300 days) disease.

CONCLUSION

This analysis demonstrates a survival benefit for initially untreated patients with advanced disease who migrate to another hospital for treatment. Migration was associated with having private insurance, thus making it noteworthy of the relationship between NSCLC survival benefit and insurance status.

Trends in Cancer Survival by Health Insurance Status in California From 1997 to 2014

Importance

There have been substantial improvements in the early detection, treatment, and survival from cancer in the United States, but it is not clear to what extent patients with different types of health insurance have benefitted from these advancements.

Objective

To examine trends in cancer survival by health insurance status from January 1997 to December 2014.

Design, Setting, and Participants

California Cancer Registry (a statewide cancer surveillance system) data were used to estimate population-based survival by health insurance status in 3 calendar periods: January 1997 to December 2002, January 2003 to December 2008, and January 2009 to December 2014 with follow-up through 2014. Overall, 1 149 891 patients diagnosed with breast, prostate, colorectal, or lung cancer, or melanoma in California were included in the study.

Main Outcomes and Measures

Five-year all-cause and cancer-specific survival probabilities by insurance category and calendar period for each cancer site and sex; hazard ratios (HRs) and 95% CIs for each insurance category (none, Medicare, other public) compared with private insurance in each calendar period.

Results

According to data from 1 149 891 patients diagnosed with breast, prostate, colorectal, or lung cancer, or melanoma gathered from the California Cancer Registry, improvements in survival were almost exclusively limited to patients with private or Medicare insurance. For patients with other public or no insurance, survival was largely unchanged or declined. Relative to privately insured patients, cancer-specific mortality was higher in uninsured patients for all cancers except prostate, and disparities were largest from 2009 to 2014 for breast (HR, 1.72; 95% CI, 1.45-2.03), lung (men: HR, 1.18; 95% CI, 1.06-1.31 and women: HR, 1.32; 95% CI, 1.15-1.50), and colorectal cancer (women: HR, 1.30; 95% CI, 1.05-1.62). Mortality was also higher for patients with other public insurance for all cancers except lung, and disparities were largest from 2009 to 2014 for breast (HR, 1.25; 95% CI, 1.17-1.34), prostate (HR, 1.17; 95% CI, 1.04-1.31), and colorectal cancer (men: HR, 1.16; 95% CI, 1.08-1.23 and women: HR, 1.11; 95% CI, 1.03-1.20).

Conclusions and Relevance

After accounting for patient and clinical characteristics, survival disparities for men with prostate cancer and women with lung or colorectal cancer increased significantly over time, reflecting a lack of improvement in survival for patients with other public or no insurance. To mitigate these growing disparities, all patients with cancer need access to health insurance that covers all the necessary elements of health care, from prevention and early detection to timely treatment according to clinical guidelines.

The Impact of the Affordable Care Act on Disparities in Private and Medicaid Insurance Coverage Among Patients Under 65 With Newly Diagnosed Cancer

PURPOSE

To investigate the impact of the Affordable Care Act on racial and rural-urban disparities in insurance coverage for patients under age 65 with cancer.

METHODS AND MATERIALS

Using the Surveillance, Epidemiology, and End Results data from 2011 to 2015, we calculated the proportions of uninsured, Medicaid, and non-Medicaid insured (including private insurance) patients before and after the Medicaid expansion. We calculated the absolute percent change and difference in differences (DiD) to evaluate whether the Medicaid expansion had an impact on the distribution of types of insurance. Adjusted DiD analyses accounted for age, race, sex, county-level median household income, and rural-urban residence.

RESULTS

There was a greater decrease in uninsured rate in expansion states (-3.0%) versus nonexpansion states (-0.9%, DiD -2.1%), particularly among Black (DiD -3.4%), Hispanic (-3.9%), and rural patients (-4.8%). In expansion states, an increase in the proportion of patients with Medicaid coincided with a decrease in the proportion with non-Medicaid insurance; the opposite was observed in nonexpansion states. The decrease in non-Medicaid insurance varied by patient race: Asian/Pacific Islanders (adjusted DiD -9.7%), Hispanic (-4.2%), non-Hispanic black (-4.0%), and non-Hispanic white (-2.8%).

CONCLUSIONS

Medicaid expansion versus nonexpansion states observed a slightly greater reduction in the uninsured rate, but Medicaid expansion states also observed a corresponding shift from non-Medicaid (including private) to Medicaid insurance, which may paradoxically exacerbate disparities in access to care and cancer outcomes. Long-term outcomes and continued study are required to fully understand the impact of the Affordable Care Act on disparities in cancer care.

Variations in Medicaid Payment Rates for Radiation Oncology

PURPOSE

Interstate variations in Medicaid reimbursements can be significant, and patients who live in states with low Medicaid reimbursements tend to have worse access to care. This analysis describes the extent of variations in Medicaid reimbursements for radiation oncology services across the United States.

METHODS AND MATERIALS

The Current Procedural Terminology codes billed for a course of whole breast radiation were identified for this study. Publicly available fee schedules were queried for all 50 states and Washington, DC, to determine the reimbursement for each service and the total reimbursement for the entire episode of care. The degree of interstate payment variation was quantified by computing the range, mean, standard deviation, and coefficient of variation. The cost of care for the entire episode of treatment was compared to the publicly available Kaiser Family Foundation (KFF) Medicaid-to-Medicare fee index to determine if the pattern of payment variation in medical services generally is predictive of the variation seen in radiation oncology specifically.

RESULTS

Data were available for 48 states and Washington, DC. The total episode reimbursement (excluding image guidance for respiratory tracking) varied from $2945 to $15,218 (mean, $7233; standard deviation, $2248 or 31%). The correlation coefficient of the KFF index to the calculated entire episode of care for each state was 0.55.

CONCLUSIONS

There is considerable variability in coverage and payments rates for radiation oncology services under Medicaid, and these variations track modestly with broader medical fees based on the KFF index. These variations may have implications for access to radiation oncology services that warrant further study.

Addressing Financial Barriers to Patient Participation in Clinical Trials: ASCO Policy Statement

Research conducted through clinical trials is essential for evaluating new treatment modalities, establishing new standards of cancer care, and ultimately improving and prolonging the lives of patients with cancer. However, participation in trials has been low, and this is attributable to various factors including patient financial barriers. Such financial barriers include the rising cost of cancer care; a lack of transparency in coverage policy; and the perception of ethical, compliance, or institutional impediments to patient financial support. ASCO convened a roundtable discussion with a variety of stakeholders to define the scope of the problem, as well as to identify clinical practice and policy solutions applicable at the institutional and system-wide levels. This statement summarizes key discussions from the ASCO Roundtable, as well as findings from the literature, and provides ASCO's recommendations for overcoming financial barriers that may otherwise prevent participation in clinical trials. These recommendations broadly address the following key areas: (1) improving the policy environment for coverage of clinical trials; (2) facilitating transparency among providers, patients, and payers for trial-related out-of-pocket costs; (3) refuting the specter of inducement to enable targeted financial support for patients; and (4) improving the available data on costs of cancer clinical trials.

Patient Protection and Affordable Care Act Medicaid expansion and gains in health insurance coverage and access among cancer survivors

BACKGROUND

The Patient Protection and Affordable Care Act extends Medicaid coverage to millions of low-income adults, including many survivors of cancer who were unable to purchase affordable health insurance coverage in the individual health insurance market.

METHODS

Using data from the 2011 to 2015 Behavioral Risk Factor Surveillance System, the authors compared changes in coverage and health care access measures for low-income cancer survivors in states that did and did not expand Medicaid.

RESULTS

The study population of 17,381 individuals included adults aged 18 to 64 years, and was predominantly female, white, and unmarried. The authors found a relative reduction in the uninsured rate of 11.7 percentage points and a relative increase in the probability of having a personal physician of 5.8 percentage points. Stratifying by whether states expanded Medicaid by 2015, the authors found that relative gains in coverage and access were larger among those individuals residing in states with expanded Medicaid compared with those residing in nonexpansion states.

CONCLUSIONS

The results of the current study suggest that the Patient Protection and Affordable Care Act Medicaid expansion has improved coverage and access for cancer survivors. Cancer 2018;124:2645-52. © 2018 American Cancer Society.

Impact of Insurance Coverage on Outcomes in Primary Breast Sarcoma

Private insurance is associated with better outcomes in multiple common cancers. We hypothesized that insurance status would significantly impact outcomes in primary breast sarcoma (PBS) due to the additional challenges of diagnosing and coordinating specialized care for a rare cancer. Using the National Cancer Database, we identified adult females diagnosed with PBS between 2004 and 2013. The influence of insurance status on overall survival (OS) was evaluated using the Kaplan-Meier estimator with log-rank tests and Cox proportional hazard models. Among a cohort of 607 patients, 67 (11.0%) had Medicaid, 217 (35.7%) had Medicare, and 323 (53.2%) had private insurance. Compared to privately insured patients, Medicaid patients were more likely to present with larger tumors and have their first surgical procedure further after diagnosis. Treatment was similar between patients with comparable disease stage. In multivariate analysis, Medicaid (hazard ratio (HR), 2.47; 95% confidence interval (CI), 1.62-3.77; p < 0.001) and Medicare (HR, 1.68; 95% CI, 1.10-2.57; p=0.017) were independently associated with worse OS. Medicaid insurance coverage negatively impacted survival compared to private insurance more in breast sarcoma than in breast carcinoma (interaction p < 0.001). In conclusion, patients with Medicaid insurance present with later stage disease and have worse overall survival than privately insured patients with PBS. Worse outcomes for Medicaid patients are exacerbated in this rare cancer.

Health Care Disparities in Cancer Patients Receiving Radiation: Changes in Insurance Status After Medicaid Expansion Under the Affordable Care Act

PURPOSE

To compare insurance status in cancer patients receiving radiation before and after Medicaid expansion under the Patient Protection and Affordable Care Act (ACA), in both expanded and non-expanded states.

METHODS AND MATERIALS

Newly diagnosed cancer patients aged 18 to 64 years who received radiation from 2011 to 2014 were compiled from the Surveillance, Epidemiology, and End Results database. Patients with a prior cancer diagnosis or unknown insurance status were excluded. Insurance rates at diagnosis were examined before (2011-2013) and after Medicaid expansion (2014) and compared between states that fully or did not fully expand Medicaid.

RESULTS

A total of 197,290 patients were analyzed. Of these, 73% lived in expanded states. After expansion, there was a 53% relative decrease in uninsured rates in expanded states (4.3%-2.1%) and a 5% relative decrease in non-expanded states (8.4%-8.0%) (P < .0001). In expanded states, the uninsured rate decreased regardless of race (whites: relative decrease 56%, 4.3% to 1.9%; blacks: relative decrease 50%, 6.0 to 3.0%; both P < .0001) or county poverty level (low poverty: relative decrease 46%, 3.9% to 2.1%; high poverty: relative decrease 60%, 4.5% to 1.8%; both P < .0001). In non-expanded states, a decrease in uninsured levels was seen primarily in whites (relative decrease 9%, 7.8% to 7.1%, P < .0001; blacks: relative increase 7%, 9.9% to 10.6%, P = .37) and those living in areas with the lowest poverty (relative decrease 27%, 4.8% to 3.5%, P = .04; high poverty: relative increase 2%, 10.9% to 11.1%, P = .17). Blacks and those living in the highest poverty areas had the greatest level of benefit from full expansion (absolute benefit 2.0%-2.3%, P = .0093 and P = .0029, respectively).

CONCLUSIONS

Medicaid expansion in 2014 significantly decreased uninsured rates for cancer patients receiving radiation. Full expansion decreased rates of uninsurance to a greater degree and seemed to decrease racial and economic disparities.

Sociodemographic disparities in survival for adolescents and young adults with cancer differ by health insurance status

PURPOSE

To investigate associations of sociodemographic factors-race/ethnicity, neighborhood socioeconomic status (SES), and health insurance-with survival for adolescents and young adults (AYAs) with invasive cancer.

METHODS

Data on 80,855 AYAs with invasive cancer diagnosed in California 2001-2011 were obtained from the California Cancer Registry. We used multivariable Cox proportional hazards regression to estimate overall survival.

RESULTS

Associations of public or no insurance with greater risk of death were observed for 11 of 12 AYA cancers examined. Compared to Whites, Blacks experienced greater risk of death, regardless of age or insurance, while greater risk of death among Hispanics and Asians was more apparent for younger AYAs and for those with private/military insurance. More pronounced neighborhood SES disparities in survival were observed among AYAs with private/military insurance, especially among younger AYAs.

CONCLUSIONS

Lacking or having public insurance was consistently associated with shorter survival, while disparities according to race/ethnicity and neighborhood SES were greater among AYAs with private/military insurance. While health insurance coverage associates with survival, remaining racial/ethnic and socioeconomic disparities among AYAs with cancer suggest additional social factors also need consideration in intervention and policy development.

Association of Insurance Status with the Use of Immediate Breast Reconstruction in Women with Breast Cancer

Our group sought to determine the influence of health insurance coverage on use of immediate breast reconstruction for working-age women undergoing mastectomy for breast cancer.

The impact of health insurance on cancer care in disadvantaged communities

BACKGROUND

Individuals from disadvantaged communities are among the millions of uninsured Americans gaining insurance under the Affordable Care Act. The extent to which health insurance can mitigate the effects of the social determinants of health on cancer care is unknown.

METHODS

This study linked the Surveillance, Epidemiology, and End Results registries to US Census data to study patients diagnosed with the 4 leading causes of cancer deaths between 2007 and 2011. A county-level social determinant score was developed with 5 measures of wealth, education, and employment. Patients were stratified into quintiles, with the lowest quintile representing the most disadvantaged communities. Logistic regression and Cox proportional hazards models were used to estimate associations and cancer-specific survival.

RESULTS

A total of 364,507 patients aged 18 to 64 years were identified (134,105 with breast cancer, 106,914 with prostate cancer, 62,606 with lung cancer, and 60,882 with colorectal cancer). Overall, patients from the most disadvantaged communities (median household income, $42,885; patients below the poverty level, 22%; patients completing college, 17%) were more likely to present with distant disease (odds ratio, 1.6; P < .001) and were less likely to receive cancer-directed surgery (odds ratio, 0.8; P < .001) than the least disadvantaged communities (median income, $78,249; patients below the poverty level, 9%; patients completing college, 42%). The differences persisted across quintiles regardless of the insurance status. The effect of having insurance on cancer-specific survival was more pronounced in disadvantaged communities (relative benefit at 3 years, 40% vs 31%). However, it did not fully mitigate the effect of social determinants on mortality (hazard ratio, 0.75 vs 0.68; P < .001).

CONCLUSIONS

Cancer patients from disadvantaged communities benefit most from health insurance, and there is a reduction in disparities in outcome. However, the gap produced by social determinants of health cannot be bridged by insurance alone. Cancer 2017;123:1219-1227. © 2016 American Cancer Society.

Insurance status and disparities in disease presentation, treatment, and outcomes for men with germ cell tumors

BACKGROUND

People aged 26 to 34 years represent the greatest proportion of the uninsured, and they have the highest incidence of testicular cancers. The aim of this study was to investigate the association between insurance status and cancer outcomes in men diagnosed with germ cell tumors.

METHODS

The Surveillance, Epidemiology, and End Results database was used to identify 10,211 men diagnosed with germ cell gonadal neoplasms from 2007 to 2011. Associations between insurance status and characteristics at diagnosis and receipt of treatment were examined with log-binomial regression. The association between insurance status and mortality was assessed with Cox proportional hazards regression.

RESULTS

Uninsured patients had an increased risk of metastatic disease at diagnosis (relative risk [RR], 1.26; 95% confidence interval [CI], 1.15-1.38) in comparison with insured patients, as did Medicaid patients (RR, 1.62; 95% CI, 1.51-1.74). Among men with metastatic disease, uninsured and Medicaid patients were more likely to be diagnosed with intermediate/poor-risk disease (RR for uninsured patients, 1.22; 95% CI, 1.04-1.44; RR for Medicaid patients, 1.39; 95% CI, 1.23-1.57) and were less likely to undergo lymph node dissection (RR for uninsured patients, 0.74; 95% CI, 0.57-0.94; RR for Medicaid patients, 0.76; 95% CI, 0.63-0.92) in comparison with insured patients. Men without insurance were more likely to die of their disease (hazard ratio [HR], 1.88; 95% CI, 1.29-2.75) in comparison with insured men, as were those with Medicaid (HR, 1.51; 95% CI, 1.08-2.10).

CONCLUSIONS

Patients without insurance and patients with Medicaid have an increased risk of presenting with advanced disease and dying of the disease in comparison with those who have insurance. Future studies should examine whether implementation of the Patient Protection and Affordable Care Act reduces these disparities. Cancer 2016;122:3127-35. © 2016 American Cancer Society.

A brighter future? The impact of insurance and socioeconomic status on cancer outcomes in the USA: a review

Uninsured and Medicaid-insured cancer patients have been shown to present with more advanced disease, less often receive cancer-directed therapy and suffer higher rates of mortality than those with private insurance. The Patient Protection and Affordable Care Act was signed into law in March of 2010 and seeks to increase rates of public and private health insurance. Although several provisions will in particular benefit those with chronic and high-cost medical conditions such as cancer, the extent to which disparities in cancer care will be eliminated is uncertain. Further legislative changes may be needed to ensure equal and adequate cancer care for all patients regardless of insurance or socioeconomic status.