Comparison of Insurance Status and Diagnosis Stage Among Patients With Newly Diagnosed Cancer Before vs After Implementation of the Patient Protection and Affordable Care Act
Comparison of Insurance Status and Diagnosis Stage Among Patients With Newly Diagnosed Cancer Before vs After Implementation of the Patient Protection and Affordable Care Act
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DOI：
10.1001/jamaoncol.2018.3467
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发表时间：
2018-12-01
期刊：
影响因子：
28.4
通讯作者：
Jemal, Ahmedin
中科院分区：
文献类型：
--
作者：
Han, Xuesong;Yabroff, Robin;Jemal, Ahmedin
在美国，拥有医疗保险的重要性是癌症结局的一个重要决定因素，根据患者保护和平价医疗法案(ACA)扩大医疗补助可能降低了未参保患者的患病率。以前的研究只评估了扩展的总体影响，对于未参保患者按州和关键社会人口学群体的变化知之甚少，包括性别、种族/民族、人口普查地区水平贫困和农村。目的检查ACAS实施后未参保患者百分比和非老年癌症患者中诊断阶段的变化。设计、背景和参与者本研究使用差异分析来确定在40个州(2010年1月1日至12月31日)之前基于人口的癌症登记中18岁至岁的未参保患者和早期癌症诊断患者的百分比2013年)和ACA医疗补助扩大后(2014年1月1日至2014年12月31日)。对2017年11月至2018年4月的数据进行分析。主要结果和衡量未参保患者百分比和早期诊断的变化。结果共有2471 154名患者(平均年龄52.7岁；年龄范围18-；51.4%女性；70.9%非西班牙裔白人)包括医疗补助扩大(n=1234 156)和未扩大(n=1236 998)状态。2014年，几乎所有州的未参保患者比例都有所下降。然而，扩张状态下的降幅比非扩张状态下的更大，并且在基线未投保率较高的扩张状态下降幅最大。例如，肯塔基州扩张州的未参保患者比例从实施ACA前的8.3%下降到实施ACA后的2.1%(差异-6.2)，而田纳西州未扩张州的未参保患者比例从9.1%下降到7.5%(差异-1.5)。在扩张州，少数族裔和高度贫困或农村地区的患者中，未参保患者比例的下降幅度更高，缩小或消除了差异。相比之下，在未扩大的州，未参保患者比例的社会人口学差异仍然很高。对于大多数处于医疗补助扩展状态的癌症类型，诊断时的阶段略有转移到早期阶段。结论和相关性本研究发现，实施ACA后，非老年癌症患者中未参保患者的百分比下降了，扩展状态的下降幅度大于非扩展状态。在医疗补助扩展州，未参保患者比例按种族/民族、人口普查地区水平的贫困和农村地区的差异缩小或消除，但在非扩展州仍然很高，突显了医疗补助扩展在缩小社会人口亚群之间差异方面的前景。未来的研究应该监测ACA实施后癌症表现、治疗和结果的变化。
IMPORTANCE Having health insurance is a strong determinant of cancer outcomes in the United States, and Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) may have reduced the prevalence of uninsured patients. Prior research has only assessed the aggregate effects of expansions, and little is known about changes in uninsured patients by state and key sociodemographic groups, including sex, race/ethnicity, census tract-level poverty, and rurality.OBJECTIVE To examine changes in the percentage of uninsured patients and stage at diagnosis among nonelderly patients with cancer by state and key sociodemographic groups after implementation of the ACA.DESIGN, SETTING, AND PARTICIPANTS This study used difference-in-differences analysis to determine the percentage of uninsured patients and early-stage cancer diagnoses among patients aged 18 to 64 years from the population-based cancer registries of 40 states before (January 1, 2010, to December 31, 2013) and after (January 1, 2014, to December 31, 2014) the ACA Medicaid expansion. Data analysis was performed from November 2017 to April 2018.MAIN OUTCOMES AND MEASURES Changes in the percentage of uninsured patients and early-stage diagnoses.RESULTS A total of 2 471 154 patients (mean age, 52.7 years; age range, 18-64 years; 51.4% female; 70.9% non-Hispanic white) were included from Medicaid expansion (n = 1 234 156) and nonexpansion (n = 1 236 998) states. In 2014, the percentage of uninsured patients decreased in almost all states. However, decreases were greater in expansion than nonexpansion states and were greatest in expansion states with high baseline uninsured rates. For example, the percentage of uninsured patients decreased from 8.3% before implementation of the ACA to 2.1%(-6.2 difference) after implementation of the ACA in the expansion state of Kentucky compared with 9.1% to 7.5%(-1.5 difference) in the nonexpansion state of Tennessee. In expansion states, the decreases in the percentage of uninsured patients were higher among minorities and patients in high-poverty or rural areas, diminishing or eliminating disparities. In contrast, sociodemographic disparities in the percentage of uninsured patients remained high in nonexpansion states. Stage at diagnosis shifted slightly to earlier stage for most cancer types in Medicaid expansion states.CONCLUSIONS AND RELEVANCE This study found state variation in reductions in the percentage of uninsured patients among nonelderly patients with cancer after implementation of the ACA, with larger decreases in expansion than nonexpansion states. Disparities in the percentage of uninsured patients by race/ethnicity, census tract-level poverty, and ruralitywere diminished or eliminated in Medicaid expansion states but remained high in nonexpansion states, highlighting the promising role of Medicaid expansion in reducing disparities among sociodemographic subpopulations. Future studies should monitor changes in cancer presentation, treatment, and outcomes after implementation of the ACA.