The Effect of The Affordable Care Act on Insurance Status in Patients with Primary Breast Cancer
Neel R. Sangal1, Farrah C. Liu1, Archana Babu1, Jonathan D. Keith, MD2, Edward S. Lee1.
1Rutgers New Jersey Medical School, Boston, MA, USA, 2Rutgers New Jersey Medical School, Newark, NJ, USA.
Background: The relationship between insurance status and survival outcomes in patients with cancer has been well established. Uninsured patients have increased probability for complications after cancer-directed surgery and have prolonged hospital stays. These patients also have greater odds of in-hospital mortality. In 2010, the Affordable Care Act was enacted, greatly increasing insurance coverage in the general population. Many provisions have since been implemented into health programs systematically. In 2014, expansion of Medicaid eligibility in some states played a role in further expanding insurance coverage.
Methods: The SEER registry was queried for BC diagnosed between 2011 and 2014. Rates of uninsured status were compared before and after Medicaid expansion and contrasted between states that did and did not expand coverage, stratified by inherent patient and tumor characteristics, and assessed via multivariate regression. Results: 74,954 patients with BC were identified between 2011 and 2014. There were no significant differences in demographic, clinicopathologic, and treatment characteristics of the cohorts pre- and post- Medicaid expansion. Overall rates of uninsured status (UR) were decreased by 35.3% in states that did expand coverage (ES) but increased by 10.7% in states that did not expand coverage (NS). In NS, there was an increase in proportion of black patients who were uninsured over the study period (11.6%) whereas in ES, this proportion decreased by 40.6%. There was an increase in uninsured rate in suburban population density regions (1.9% to 2.8%) in nonexpansion states and a decrease (1.7% to 0.8%) in expansion states. Multivariate analysis yielded predictors of uninsured status, including age, race, marital status, population density, year of diagnosis, and residence in non-expansion state. Conclusion: This study demonstrates that implementation of the Affordable Care Act resulted in increased insurance coverage for patients diagnosed with malignancies of the breast. We find the differences in uninsured rates were most significantly decreased in states that expanded their coverage and in vulnerable populations. Furthermore, insurance status is important in determining survival in multivariate models. These findings should inform further policy direction surrounding Medicaid expansion for patients with breast cancers.
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