The Impact of the Affordable Care Act and Medicaid Expansion on Insurance Status and Cancer Staging for Bladder Cancer Patients
Insurance status is a known barrier in access to healthcare for patients with bladder cancer (BCa) and is associated with differences in initial staging. This study examined the impact of the Affordable Care Act (ACA) and associated Medicaid expansion on the insurance status and staging of BCa patients in the United States.
Cases were identified from the National Cancer Database-Participant User File from 2004-2015. Patients were selected by year of diagnosis: prior to the passing of the ACA (2004-2009) and after the Medicaid expansion provision (2014-2015). National data was analyzed, as well as the Pacific (PR: AK, CA, HI, OR, WA) and West South Central (WSC: AR, LA, OK, TX) regions, to sample early and non-Medicaid expanding states, respectively. Chi-squared test was used to compare patient and disease characteristics. Multivariable logistic regression was used to estimate odds ratios for a stage IV BCa diagnosis within regions, controlling for age, gender, race, and comorbidities.
This study included 282,980 patients with BCa: 30,350 in the PR, and 15,969 in the WSC. Prior to the Medicaid expansion, uninsured patients were at significantly higher risk to present with stage IV BCa, and at even higher risk if they had Medicaid, in all three study groups (OR uninsured: Nationally 1.9 (p<0.001 (CI 1.7-2.1)), PR 1.5 (p=0.019 (CI 1.1-2.2)), WSC 1.8 (p<0.001 (CI 1.3-2.5)); Medicaid: Nationally 2.3 (p<0.001 (CI 2.1-2.6)), PR 2.3 (p<0.001 (CI 1.8-2.8)), WSC 2.5 (p<0.001 (CI 1.8-3.6)). Following expansion, the risk remained elevated for these groups Nationally, but did decrease (OR uninsured 1.8 (p<0.001 (CI 1.5-2.1)), Medicaid 1.7 (p<0.001 (CI 1.5-1.9)). Patients in the PR with Medicaid had a persistent elevated risk (OR 1.8 (p<0.001 (CI 1.3-2.5)). In the WSC, those without insurance had an increased risk of stage IV disease (OR 2.2 (p<0.001 (CI 1.5-3.2)), and those with Medicaid had a persistent elevated risk (OR 2.4 (p=0.002 (CI 1.4-4.1)).</p>
Prior to the ACA, patients without insurance and those with Medicaid were more likely to present with stage IV BCa than those on private insurance, with Medicaid being more likely than the uninsured in all regions. In the two years post-expansion, these odds decreased for both the uninsured and Medicaid populations, with Medicaid reducing their odds below that of the uninsured Nationally. A prominent reduction in these odds was seen for Medicaid in the PR, along with increased odds for the uninsured in the WSC region, however the Medicaid risk was still higher than the uninsured in both regions.