Association of Medicaid Expansion Under the Affordable Care Act With Insurance Status, Cancer Stage, and Timely Treatment Among Patients With Breast, Colon, and Lung Cancer
Association of Medicaid Expansion Under the Affordable Care Act With Insurance Status, Cancer Stage, and Timely Treatment Among Patients With Breast, Colon, and Lung Cancer
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DOI：
10.1001/jamanetworkopen.2019.21653
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发表时间：
2020-02-19
影响因子：
13.8
通讯作者：
Werner, Rachel M.
中科院分区：
文献类型：
--
作者：
Takvorian, Samuel U.;Oganisian, Arman;Werner, Rachel M.
这项横断面研究探讨了医疗补助扩张后的患者保护和平价医疗法案（ACA）和保险状态的变化之间的关联，癌症诊断阶段，并及时治疗患者之间的事件乳腺癌，结肠癌，和非小细胞肺癌。重要性的影响患者保护和平价医疗法案的医疗补助扩张对癌症护理交付和结果是未知的。癌症患者是一个高风险群体，治疗延误对他们特别有害。目的探讨医疗补助范围扩大与乳腺癌、结肠癌和非小细胞肺癌患者的保险状况、诊断分期和及时治疗的变化之间的关系。设计、设置和参与者这项准实验性、差异中差异（DID）横断面研究包括非老年人。（年龄40-64岁），从2011年1月1日至2016年12月31日，在国家癌症数据库中新诊断为浸润性乳腺癌、结肠癌或非小细胞肺癌，这是一个基于医院的登记处，记录了美国70%以上的癌症诊断病例。数据分析时间为2019年3月8日至8月15日。暴露居住在一个国家，扩大医疗补助于2014年1月1日。主要结果和测量主要结果是保险状况、癌症分期和诊断后30天和90天内的及时治疗。结果925543例患者（78.6%的女性;平均[SD]年龄，55.0 [6.5]岁; 14.2%的黑人; 5.7%的西班牙裔）新诊断为浸润性乳腺癌（58.9%），结肠癌（14.6%）或非小细胞肺癌（26.5%）; 48.3%居住在医疗补助扩展状态，51.7%居住在非扩展状态。与非扩张状态相比，扩张状态下未投保患者的百分比下降更多（调整后的DID，-0.7 [95%CI，-1.2至0.3]个百分点），早期癌症诊断的百分比在扩张状态下上升更多（调整后的DID，0.8 [95%CI，0.3至1.2]个百分点）。在诊断后365天内接受癌症导向治疗的848329例患者中，30天内接受治疗的百分比从扩张前的52.7%下降至扩张后的48.0%（差异，-4.7 [95% CI，-5.1至-4.5]个百分点）。在非扩展状态下，这一百分比从56.9%下降到51.5%（差异，-5.4 [95% CI，-5.6至5.1]个百分点），在与医疗补助扩展相关的及时治疗方面没有统计学显著的DID（调整后的DID，0.6 [95% CI，-0.2至1.4]个百分点）。结论和相关性本研究发现，在乳腺癌、结肠癌和肺癌患者中，医疗补助的扩大与未投保患者的比例下降和早期癌症诊断率的增加有关;没有发现及时治疗率提高或降低的证据，需要进一步研究以了解医疗补助扩大对患者治疗模式和健康结果的影响问题：在《患者保护和平价医疗法案》实施三年后，医疗补助的扩大是否与保险状态和诊断时癌症分期的变化有关，而不会延迟治疗时间？结果在这项对925543例乳腺癌、结肠癌和肺癌患者的横断面研究中，医疗补助的扩大与未投保患者的发病率下降和早期癌症诊断率增加相关;它与及时治疗率的变化无关。在新诊断的乳腺癌、结肠癌和肺癌患者中，医疗补助的扩大与保险覆盖范围的增加和早期癌症诊断相关，而没有治疗延迟的证据。
This cross-sectional study examines the association between Medicaid expansion following the Patient Protection and Affordable Care Act (ACA) and changes in insurance status, cancer stage at diagnosis, and timely treatment among patients with incident breast, colon, and non-small cell lung cancer.Importance The effect of the Patient Protection and Affordable Care Act's Medicaid expansion on cancer care delivery and outcomes is unknown. Patients with cancer are a high-risk group for whom treatment delays are particularly detrimental. Objective To examine the association between Medicaid expansion and changes in insurance status, stage at diagnosis, and timely treatment among patients with incident breast, colon, and non-small cell lung cancer. Design, Setting, and Participants This quasi-experimental, difference-in-differences (DID) cross-sectional study included nonelderly adults (aged 40-64 years) with a new diagnosis of invasive breast, colon, or non-small cell lung cancer from January 1, 2011, to December 31, 2016, in the National Cancer Database, a hospital-based registry capturing more than 70% of incident cancer diagnoses in the United States. Data were analyzed from March 8 to August 15, 2019. Exposures Residence in a state that expanded Medicaid on January 1, 2014. Main Outcomes and Measures The primary outcomes were insurance status, cancer stage, and timely treatment within 30 and 90 days of diagnosis. Results A total of 925543 patients (78.6% women; mean [SD] age, 55.0 [6.5] years; 14.2% black; and 5.7% Hispanic) had a new diagnosis of invasive breast (58.9%), colon (14.6%), or non-small cell lung (26.5%) cancer; 48.3% resided in Medicaid expansion states and 51.7% resided in nonexpansion states. Compared with nonexpansion states, the percentage of uninsured patients decreased more in expansion states (adjusted DID, -0.7 [95% CI, -1.2 to -0.3] percentage points), and the percentage of early-stage cancer diagnoses rose more in expansion states (adjusted DID, 0.8 [95% CI, 0.3 to 1.2] percentage points). Among the 848329 patients who underwent cancer-directed therapy within 365 days of diagnosis, the percentage treated within 30 days declined from 52.7% before to 48.0% after expansion in expansion states (difference, -4.7 [95% CI, -5.1 to -4.5] percentage points). In nonexpansion states, this percentage declined from 56.9% to 51.5% (difference, -5.4 [95% CI, -5.6 to -5.1] percentage points), yielding no statistically significant DID in timely treatment associated with Medicaid expansion (adjusted DID, 0.6 [95% CI, -0.2 to 1.4] percentage points). Conclusions and Relevance This study found that, among patients with incident breast, colon, and lung cancer, Medicaid expansion was associated with a decreased rate of uninsured patients and increased rate of early-stage cancer diagnosis; no evidence of improvement or decrement in the rate of timely treatment was found. Further research is warranted to understand Medicaid expansion's effect on the treatment patterns and health outcomes of patients with cancer.Question Three years after implementation of the Patient Protection and Affordable Care Act, was Medicaid expansion associated with changes in insurance status and cancer stage at diagnosis without delaying time to treatment? Findings In this cross-sectional study of 925543 patients with incident breast, colon, and lung cancer, Medicaid expansion was associated with a decreased rate of uninsured patients and an increased rate of early-stage cancer diagnosis; it was not associated with changes in the rate of timely treatment. Meaning Among patients with newly diagnosed breast, colon, and lung cancer, Medicaid expansion was associated with increased insurance coverage and earlier-stage cancer diagnosis without evidence of treatment delay.