Association of Medicaid Expansion Under the Affordable Care Act With Breast Cancer Stage at Diagnosis
Association of Medicaid Expansion Under the Affordable Care Act With Breast Cancer Stage at Diagnosis
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DOI：
10.1001/jamasurg.2020.1495
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发表时间：
2020-08-01
期刊：
影响因子：
16.9
通讯作者：
Park, Tristen S.
中科院分区：
文献类型：
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作者：
Le Blanc, Justin M.;Heller, Danielle R.;Park, Tristen S.
扩大医疗补助计划旨在填补低收入美国人在保险覆盖方面的空白。尽管覆盖面有所提高，但人们对医疗补助扩大与乳腺癌诊断阶段之间的关系知之甚少。目的回顾医疗补助扩大与乳腺癌诊断阶段的关系，以及与保险状况、年龄和种族/民族相关的差异。本队列研究使用来自国家癌症数据库的数据来描述乳腺癌分期与种族/民族、年龄和保险状况之间的关系。获得了2007年至2016年的数据，并评估了乳腺癌分期趋势。此外，将扩张前年份（2012-2013）与扩张后年份（2015-2016）进行比较，以评估2014年的医疗补助扩张情况。数据分析时间为2019年8月12日至2020年1月19日。该队列共包括45个州的1.796.902名患有原发性乳腺癌的患者，他们有私人保险、医疗保险或医疗补助，或者没有保险。未参保乳腺癌患者的百分比变化和诊断时的分期，按参保状况、种族/民族、年龄和州进行分层。结果本研究共纳入1 796 902名女性。在2012年至2016年期间，71235人（4.0%）没有保险或有医疗补助。在所有种族/民族中，在扩张州，未参保患者从22.6%（21 127人中4771人）减少到13.5%（22 150人中2999人）（P < 0.001），在非扩张州，未参保患者从36.5%（14.870人中5431人）减少到35.6%（13 088人中4663人）（P = 0.12）。在所有种族中，扩张状态的晚期疾病发生率从21.8%（21 127人中4603人）降至19.3%（22 150人中4280人）（P < 0.001），而非扩张状态的晚期疾病发生率从24.2%（14 870人中3604人）降至23.5%（13 088人中3072人）（P = 0.14）。在非裔美国患者中，扩张状态的晚期疾病发病率从24.6%（4136例中的1017例）下降到21.6%（4259例中的920例）（P < 0.001），非扩张状态的晚期疾病发病率保持在27%左右（27.4%[1220例中的4453例]到27.5%[1078例中的3924例]；P = 0.94）。进一步的分析表明，这种改善与3期诊断的减少有关。结论和相关性在这项队列研究中，医疗补助计划的扩大与未参保患者数量的减少和晚期乳腺癌发病率的降低有关。非裔美国患者和50岁以下的患者尤其受益。这些数据表明，增加获得卫生保健资源的机会可能会改变诊断时乳腺癌分期的分布。医疗补助的扩大是否改善了以前没有保险的乳腺癌患者的保险覆盖范围？基于州和保险状况，癌症诊断阶段是否存在差异？在这项对1.796.902名没有医疗保险或有医疗补助的女性患者的队列研究中，扩大医疗补助的州的未保险患者减少了9个百分点，而未扩大医疗补助的州则减少了1个百分点。扩大医疗补助计划的州晚期乳腺癌发病率下降了3个百分点，而未扩大医疗补助计划的州晚期乳腺癌发病率下降了1个百分点，这是一个显著的差异。这意味着医疗补助的扩大与没有保险的乳腺癌患者数量的减少以及晚期乳腺癌的减少有关。本队列研究使用2007年至2016年国家癌症数据库的数据，调查医疗补助扩大前后乳腺癌诊断阶段与患者保险状况、年龄和种族/民族之间的关系。
Importance The expansion of Medicaid sought to fill gaps in insurance coverage among low-income Americans. Although coverage has improved, little is known about the relationship between Medicaid expansion and breast cancer stage at diagnosis. Objective To review the association of Medicaid expansion with breast cancer stage at diagnosis and the disparities associated with insurance status, age, and race/ethnicity. Design, Setting, and Participants This cohort study used data from the National Cancer Database to characterize the relationship between breast cancer stage and race/ethnicity, age, and insurance status. Data from 2007 to 2016 were obtained, and breast cancer stage trends were assessed. Additionally, preexpansion years (2012-2013) were compared with postexpansion years (2015-2016) to assess Medicaid expansion in 2014. Data were analyzed from August 12, 2019, to January 19, 2020. The cohort included a total of 1.796.902 patients with primary breast cancer who had private insurance, Medicare, or Medicaid or were uninsured across 45 states. Main Outcomes and Measures Percent change of uninsured patients with breast cancer and stage at diagnosis, stratified by insurance status, race/ethnicity, age, and state. Results This study included a total of 1 796 902 women. Between 2012 and 2016, 71.235 (4.0%) were uninsured or had Medicaid. Among all races/ethnicities, in expansion states, there was a reduction in uninsured patients from 22.6% (4771 of 21 127) to 13.5% (2999 of 22 150) (P < .001), and in nonexpansion states, there was a reduction from 36.5% (5431 of 14.870) to 35.6% (4663 of 13 088) (P = .12). Across all races, there was a reduction in advanced-stage disease from 21.8% (4603 of 21 127) to 19.3% (4280 of 22 150) (P < .001) in expansion states compared with 24.2% (3604 of 14 870) to 23.5% (3072 of 13 088) (P = .14) in nonexpansion states. In African American patients, incidence of advanced disease decreased from 24.6% (1017 of 4136) to 21.6% (920 of 4259) (P < .001) in expansion states and remained at approximately 27% (27.4% [1220 of 4453] to 27.5% [1078 of 3924]; P = .94) in nonexpansion states. Further analysis suggested that the improvement was associated with a reduction in stage 3 diagnoses. Conclusions and Relevance In this cohort study, expansion of Medicaid was associated with a reduced number of uninsured patients and a reduced incidence of advanced-stage breast cancer. African American patients and patients younger than 50 years experienced particular benefit. These data suggest that increasing access to health care resources may alter the distribution of breast cancer stage at diagnosis.Question Did expansion of Medicaid improve insurance coverage for previously uninsured patients with breast cancer, and is there a difference in cancer stage at diagnosis based on state and insurance status? Findings In this cohort study of 1.796.902 women, among patients who were uninsured or had Medicaid, states that expanded Medicaid saw a 9 percentage-point reduction in uninsured patients compared with a 1 percentage-point reduction in nonexpansion states. States that expanded Medicaid had a 3 percentage-point decrease in late-stage breast cancer compared with a 1 percentage-point decrease in nonexpansion states, a significant difference. Meaning Expansion of Medicaid was associated with a reduction in the number of uninsured patients with breast cancer and with decreased late-stage breast cancer presentation.This cohort study uses data from the National Cancer Database from 2007 to 2016 to investigate the association between breast cancer stage at diagnosis and patient insurance status, age, and race/ethnicity before and after the expansion of Medicaid.