The impact of individual-level income predicted from the BRFSS on the association between insurance status and overall survival among adults with cancer from the SEER program.

INTRODUCTION: Among patients with cancer in the United States, Medicaid insurance is associated with worse outcomes than private insurance and with similar outcomes as being uninsured. However, prior studies have not addressed the impact of individual-level socioeconomic status, which determines Medicaid eligibility, on the associations of Medicaid status and cancer outcomes. Our objective was to determine whether differences in cancer outcomes by insurance status persist after accounting for individual-level income. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was queried for 18-64 year-old individuals with cancer from 2014-2016. Individual-level income was imputed using a model trained on Behavioral Risk Factors Surveillance Survey participants including covariates also present in SEER. The association of 1-year overall survival and insurance status was estimated with and without adjustment for estimated individual-level income and other covariates. RESULTS: A total of 416,784 cases in SEER were analyzed. The 1-yr OS for patients with private insurance, Medicaid insurance, and no insurance was 88.7%, 76.1%, and 73.7%, respectively. After adjusting for all covariates except individual-level income, 1-year OS differences were worse with Medicaid (-6.0%, 95% CI = -6.3 to -5.6) and no insurance (-6.7%, 95% CI = -7.3 to -6.0) versus private insurance. After also adjusting for estimated individual-level income, the survival difference for Medicaid patients was similar to privately insured (-0.4%, 95% CI = -1.9 to 1.1) and better than uninsured individuals (2.1%, 95% CI = 0.7 to 3.4). CONCLUSIONS: Income, rather than Medicaid status, may drive poor cancer outcomes in the low-income and Medicaid-insured population. Medicaid insurance coverage may improve cancer outcomes for low-income individuals.

Associations between Medicaid enrollment and diagnosis stage and survival among pediatric cancer patients.

BACKGROUND: Medicaid-associated disparities in childhood and adolescent (pediatric) cancer diagnosis stage and survival have been reported. However, a key limitation of prior studies is the assessment of health insurance at a single time point. To evaluate Medicaid-associated disparities more robustly, we used Surveillance, Epidemiology, and End Results (SEER)-Medicaid linked data to examine diagnosis stage and survival disparities in those (i) Medicaid-enrolled and (ii) with discontinuous and continuous Medicaid enrollment. METHODS: SEER-Medicaid linked data from 2006 to 2013 were obtained on cases diagnosed from 0 to 19 years. Medicaid enrollment was classified as enrolled versus not enrolled, with further classifications as continuous when enrolled 6 months before through 6 months after diagnosis, and discontinuous when not enrolled continuously for this period. We used multinomial logistic and Cox proportional hazards regression models to determine associations between enrollment measures, diagnosis stage, and cancer death adjusted for covariates. RESULTS: Among 21,502 cases, a higher odds of distant stage diagnoses were observed in association with Medicaid enrollment (odds ratio [OR] = 1.56, 95% confidence interval [CI]: 1.48-1.65), with the highest odds for discontinuous enrollment (OR = 2.0, 95% CI: 1.86-2.15). Among 30,654 cases, any Medicaid enrollment, continuous enrollment, and discontinuous enrollment were associated with 1.68 (95% CI: 1.35-2.10), 1.66 (95% CI: 1.35-2.05), and 1.89 (95% CI: 1.54-2.33) times higher hazards of cancer death versus no enrollment, respectively. CONCLUSIONS: Medicaid enrollment, particularly discontinuous enrollment, is associated with a higher  distant stage diagnosis odds and risk of death. This study supports the critical need for consistent health insurance coverage in children and adolescents.

Unwinding of Medicaid Continuous Enrollment Exposes Millions to Disrupted Care-"Be Kind, Rewind".

This Viewpoint discusses the causes and consequences of Medicaid unwinding and disenrollment and proposes solutions to minimize disenrollment and improve coverage uptake and health care access.

State Public Assistance Spending and Survival Among Adults With Cancer.

Importance: Social determinants of health contribute to disparities in cancer outcomes. State public assistance spending, including Medicaid and cash assistance programs for socioeconomically disadvantaged individuals, may improve access to care; address barriers, such as food and housing insecurity; and lead to improved cancer outcomes for marginalized populations. Objective: To determine whether state-level public assistance spending is associated with overall survival (OS) among individuals with cancer, overall and by race and ethnicity. Design, Setting, and Participants: This cohort study included US adults aged at least 18 years with a new cancer diagnosis from 2007 to 2013, with follow-up through 2019. Data were obtained from the Surveillance, Epidemiology, and End Results program. Data were analyzed from November 18, 2021, to July 6, 2023. Exposure: Differential state-level public assistance spending. Main Outcome and Measure: The main outcome was 6-year OS. Analyses were adjusted for age, race, ethnicity, sex, metropolitan residence, county-level income, state fixed effects, state-level percentages of residents living in poverty and aged 65 years or older, cancer type, and cancer stage. Results: A total 2 035 977 individuals with cancer were identified and included in analysis, with 1 005 702 individuals (49.4%) aged 65 years or older and 1 026 309 (50.4%) male. By tertile of public assistance spending, 6-year OS was 55.9% for the lowest tertile, 55.9% for the middle tertile, and 56.6% for the highest tertile. In adjusted analyses, public assistance spending at the state-level was significantly associated with higher 6-year OS (0.09% [95% CI, 0.04%-0.13%] per $100 per capita; P < .001), particularly for non-Hispanic Black individuals (0.29% [95% CI, 0.07%-0.52%] per $100 per capita; P = .01) and non-Hispanic White individuals (0.12% [95% CI, 0.08%-0.16%] per $100 per capita; P < .001). In sensitivity analyses examining the roles of Medicaid spending and Medicaid expansion including additional years of data, non-Medicaid spending was associated with higher 3-year OS among non-Hispanic Black individuals (0.49% [95% CI, 0.26%-0.72%] per $100 per capita when accounting for Medicaid spending; 0.17% [95% CI, 0.02%-0.31%] per $100 per capita Medicaid expansion effects). Conclusions and Relevance: This cohort study found that state public assistance expenditures, including cash assistance programs and Medicaid, were associated with improved survival for individuals with cancer. State investment in public assistance programs may represent an important avenue to improve cancer outcomes through addressing social determinants of health and should be a topic of further investigation.

State policies regulating short-term limited duration insurance plans and cancer stage at diagnosis.

Short-term limited duration insurance plans, which proliferated following 2018 federal regulations, may not provide adequate protections for patients with suspected or newly diagnosed cancer and can destabilize insurance markets for comprehensive insurance plan enrollees. Individuals aged 18-64 years with newly diagnosed cancer from 11 states during 2016-2017 and 2019 were identified from the Surveillance, Epidemiology, and End Results program. Difference-in-differences analyses were used to compare changes in early-stage cancer diagnoses from 2016-2017 to 2019 in states that prohibited vs did not regulate short-term limited duration insurance plans. In adjusted difference-in-differences analyses, early-stage diagnoses increased 0.95 percentage points (95% confidence interval = 0.53 to 1.38, P < .001) in states that prohibited short-term limited duration insurance plans vs did not regulate short-term limited duration insurance plans. State policies resulting in unavailability of short-term limited duration insurance plans were associated with an increased percentage of early-stage diagnoses.

Changes in cancer mortality after Medicaid expansion and the role of stage at diagnosis.

BACKGROUND: Medicaid expansion is associated with improved survival following cancer diagnosis. However, little research has assessed how changes in cancer stage may mediate improved cancer mortality or how expansion may have decreased population-level cancer mortality rates. METHODS: Nationwide state-level cancer data from 2001 to 2019 for individuals ages 20-64 years were obtained from the combined Surveillance, Epidemiology, and End Results National Program of Cancer Registries (incidence) and the National Center for Health Statistics (mortality) databases. We estimated changes in distant stage cancer incidence and cancer mortality rates from pre- to post-2014 in expansion vs nonexpansion states using generalized estimating equations with robust standard errors. Mediation analyses were used to assess whether distant stage cancer incidence mediated changes in cancer mortality. RESULTS: There were 17 370 state-level observations. For all cancers combined, there were Medicaid expansion-associated decreases in distant stage cancer incidence (adjusted odds ratio = 0.967, 95% confidence interval = 0.943 to 0.992; P = .01) and cancer mortality (adjusted odds ratio = 0.965, 95% confidence interval = 0.936 to 0.995; P = .022). This translates to 2591 averted distant stage cancer diagnoses and 1616 averted cancer deaths in the Medicaid expansion states. Distant stage cancer incidence mediated 58.4% of expansion-associated changes in cancer mortality overall (P = .008). By cancer site subgroups, there were expansion-associated decreases in breast, cervix, and liver cancer mortality. CONCLUSIONS: Medicaid expansion was associated with decreased distant stage cancer incidence and cancer mortality. Approximately 60% of the expansion-associated changes in cancer mortality overall were mediated by distant stage diagnoses.

The association of Medicaid expansion and pediatric cancer overall survival.

Medicaid eligibility expansion, though not directly applicable to children, has been associated with improved access to care in children with cancer, but associations with overall survival are unknown. Data for children ages 0 to 14 years diagnosed with cancer from 2011 to 2018 were queried from central cancer registries data covering cancer diagnoses from 40 states as part of the Centers for Disease Control and Prevention's National Program of Cancer Registries. Difference-in-differences analyses were used to compare changes in 2-year survival from 2011-2013 to 2015-2018 in Medicaid expansion relative to nonexpansion states. In adjusted analyses, there was a 1.50 percentage point (95% confidence interval = 0.37 to 2.64) increase in 2-year overall survival after 2014 in expansion relative to nonexpansion states, particularly for those living in the lowest county income quartile (difference-in-differences = 5.12 percentage point, 95% confidence interval = 2.59 to 7.65). Medicaid expansion may improve cancer outcomes for children with cancer.

Insurance Coverage and Forgoing Medical Appointments Because of Cost Among Cancer Survivors After 2016.

PURPOSE: The uninsured rate began rising after 2016, which some have attributed to health policies undermining aspects of the Affordable Care Act. Our primary objectives were to assess the changes in insurance coverage and forgoing medical care because of cost in cancer survivors from pre-enactment (2016) through postenactment of those policies (2019) and determine whether there were subgroups that were disproportionately affected. METHODS: The 2016-2019 Behavioral Risk Factor Surveillance System surveys were queried for 18- to 64-year-old cancer survivors. Survey-weighted logistic regression was used to assess temporal changes in (1) insurance coverage and (2) forgoing medical appointments because of cost in the preceding 12 months. RESULTS: A total of 62,669 cancer survivors were identified. The percentage of insured cancer survivors decreased from 92.4% in 2016 to 90.4% in 2019 (odds ratio for change in insurance coverage or affordability per one-year increase [ORyear], 0.92; 95% CI, 0.86 to 0.98; P = .01), translating to 161,000 fewer cancer survivors in the United States with insurance coverage. There were decreases in employer-sponsored insurance coverage (ORyear, 0.89) but increases in Medicaid coverage (ORyear, 1.17) from 2016 to 2019. Forgoing medical appointments because of cost increased from 17.9% in 2016 to 20.0% in 2019 (ORyear, 1.05; 95% CI, 1.01 to 1.1; P = .025), affecting an estimated 169,000 cancer survivors. The greatest changes were observed among individuals with low income, particularly those residing in nonexpansion states. CONCLUSION: Between 2016 and 2019, there were 161,000 fewer cancer survivors in the United States with insurance coverage, and 169,000 forwent medical care because of cost.

The Affordable Care Act and suicide incidence among adults with cancer.

BACKGROUND: Patients with cancer are at an increased suicide risk, and socioeconomic deprivation may further exacerbate that risk. The Affordable Care Act (ACA) expanded insurance coverage options for low-income individuals and mandated coverage of mental health care. Our objective was to quantify associations of the ACA with suicide incidence among patients with cancer. METHODS: We identified US patients with cancer aged 18-74 years diagnosed with cancer from 2011 to 2016 from the Surveillance, Epidemiology, and End Results database. The primary outcome was the 1-year incidence of suicide based on cumulative incidence analyses. Difference-in-differences (DID) analyses compared changes in suicide incidence from 2011-2013 (pre-ACA) to 2014-2016 (post-ACA) in Medicaid expansion relative to non-expansion states. We conducted falsification tests with 65-74-year-old patients with cancer, who are Medicare-eligible and not expected to benefit from ACA provisions. RESULTS: We identified 1,263,717 patients with cancer, 812 of whom died by suicide. In DID analyses, there was no change in suicide incidence after 2014 in Medicaid expansion vs. non-expansion states for nonelderly (18-64 years) patients with cancer (p = .41), but there was a decrease in suicide incidence among young adults (18-39 years) (- 64.36 per 100,000, 95% CI = - 125.96 to - 2.76, p = .041). There were no ACA-associated changes in suicide incidence among 65-74-year-old patients with cancer. CONCLUSIONS: We found an ACA-associated decrease in the incidence of suicide for some nonelderly patients with cancer, particularly young adults in Medicaid expansion vs. non-expansion states. Expanding access to health care may decrease the risk of suicide among cancer survivors.

Association of State Medicaid Expansion Status With Rates of Suicide Among US Adults.

Importance: In the US, suicide is the 10th leading cause of death and a serious mental health emergency. National programs that address suicide list access to mental health care as key in prevention, and more large-scale policies are needed to improve access to mental health care and address this crisis. The Patient Protection and Affordable Care Act (ACA) Medicaid Expansion Program was implemented in several states with the goal of increasing access to the health care system. Objective: To compare changes in suicide rates in states that expanded Medicaid under the ACA vs states that did not. Design, Setting, and Participants: In this cross-sectional study, state-level mortality rates were obtained from the National Center for Health Statistics for US individuals aged 20 to 64 years from January 1, 2000, to December 31, 2018. Data analysis was performed from April 18, 2021, to April 15, 2022. Exposures: Changes in suicide mortality rates among nonelderly adults before and after Medicaid expansion in expansion and nonexpansion states were compared using adjusted difference-in-differences analyses via hierarchical bayesian linear regression. Main Outcomes and Measures: Suicide rates using death by suicide as the primary measure. Results: Of the total population at risk for suicide, 50.4% were female, 13.3% were Black, 79.5% were White, and 7.2% were of other races. The analytic data set contained suicide mortality data for 2907 state-age-year units covering the general US population. A total of 553 912 deaths by suicide occurred during the study period, with most occurring in White (496 219 [89.6%]) and male (429 580 [77.6%]) individuals. There were smaller increases in the suicide rate after 2014 in Medicaid expansion (2.56 per 100 000 increase) compared with nonexpansion states (3.10 per 100 000 increase). In adjusted difference-in-differences analysis, a significant decrease of -0.40 (95% credible interval, -0.66 to -0.14) suicides per 100 000 individuals was found, translating to 1818 suicides that were averted in 2015 to 2018. Conclusions and Relevance: In this cross-sectional study, although suicide rates increased in both groups, blunting of these rates occurred among nonelderly adults in the Medicaid expansion states compared with nonexpansion states. Because this difference may be linked to increased access to mental health care, policy makers should consider suicide prevention as a benefit of expanding access to health care.

Early Medicaid Expansion and Cancer Mortality.

BACKGROUND: Although Medicaid expansion is associated with decreased uninsured rates and earlier cancer diagnoses, no study has demonstrated an association between Medicaid expansion and cancer mortality. Our primary objective was to quantify the relationship between early Medicaid expansion and changes in cancer mortality rates. METHODS: We obtained county-level data from the National Center for Health Statistics for adults aged 20-64 years who died from cancer from 2007 to 2009 (preexpansion) and 2012 to 2016 (postexpansion). We compared changes in cancer mortality rates in early Medicaid expansion states (CA, CT, DC, MN, NJ, and WA) vs nonexpansion states through a difference-in-differences analysis using hierarchical Bayesian regression. An exploratory analysis of cancer mortality changes associated with the larger-scale 2014 Medicaid expansions was also performed. RESULTS: In adjusted difference-in-differences analyses, we observed a statistically significant decrease of 3.07 (95% credible interval = 2.19 to 3.95) cancer deaths per 100 000 in early expansion vs nonexpansion states, which translates to an estimated decrease of 5276 cancer deaths in the early expansion states during the study period. Expansion-associated decreases in cancer mortality were observed for pancreatic cancer. Exploratory analyses of the 2014 Medicaid expansions showed a decrease in pancreatic cancer mortality (-0.18 deaths per 100 000, 95% confidence interval = -0.32 to -0.05) in states that expanded Medicaid by 2014 compared with nonexpansion states. CONCLUSIONS: Early Medicaid expansion was associated with reduced cancer mortality rates, especially for pancreatic cancer, a cancer with short median survival where changes in prognosis would be most visible with limited follow-up.

State Medicaid expansion status, insurance coverage and stage at diagnosis in head and neck cancer patients.

OBJECTIVES: Only one in three head and neck cancer (HNC) patients present with early-stage disease. We aimed to quantify associations between state Medicaid expansions and changes in insurance coverage rates and stage at diagnosis of HNC. METHODS: Using a quasi-experimental difference-in-differences (DID) approach and data from 26,330 cases included in the Surveillance, Epidemiology, and End Results program (2011-2015), we retrospectively examined changes in insurance coverage and stage at diagnosis of adult HNC in states that expanded Medicaid (EXP) versus those that did not (NEXP). RESULTS: There was a significant increase in Medicaid coverage in EXP (+1.6 percentage point (PP) versus) vs. NEXP (-1.8 PP) states (3.36 PP, 95% CI = 1.32, 5.41; p = 0.001), and this increase was mostly among residents of low income and education counties. We also observed a reduction in uninsured rates among HNC patients in low income counties (-4.17 PP, 95% CI = -6.84, -1.51; p = 0.002). Overall, early stage diagnosis rates were 28.3% (EXP) vs. 26.7% (NEXP), with significant increases in early stage diagnosis post-Medicaid expansion among young adults, 18-34 years (17.2 PP, 95% CI - 1.34 to 33.1, p = 0.034), females (7.54 PP, 95% CI = 2.00 to 13.10, p = 0.008), unmarried patients (3.83 PP, 95% CI = 0.30-7.35, p = 0.033), and patients with lip cancer (13.5 PP, 95% CI = 2.67-24.3, p = 0.015). CONCLUSIONS: Medicaid expansion is associated with improved insurance coverage rates for HNC patients, particularly those with low income, and increases in early stage diagnoses for young adults and women.

Change in stage of presentation of head and neck cancer in the United States before and after the affordable care act.

OBJECTIVE/HYPOTHESIS: Early diagnosis and stage at presentation, two prognostic factors for survival among patients with head and neck cancer (HNC), are significantly impacted by a patient's health insurance status. We aimed to assess the impact of the Patient Protection and Affordable Care Act (ACA) on stage at presentation across socioeconomic and demographic subpopulations of HNC patients in the United States. STUDY DESIGN: Retrospective data analysis. METHODS: The National Cancer Database, a hospital-based cancer database (2011-2015), was queried for adults aged 18-64 years and diagnosed with a malignant primary HNC. The outcome of interest was change in early-stage diagnoses between 2011-2013 (pre-ACA) and 2014-2015 (post-ACA) using logistic regression models. RESULTS: A total of 91,137 HNC cases were identified in the pre-ACA (n = 53,726) and post-ACA (n = 37,411) years. Overall, the odds of early-stage diagnoses did not change significantly post-ACA (aOR = 0.97, 95 % CI 0.94, 1.00; p = 0.081). However, based on health insurance status, HNC patients with Medicaid were significantly more likely to present with early-stage disease post-ACA (aOR = 1.12, 95 % CI 1.03, 1.21; p = 0.007). We did not observe increased odds of early-stage presentation for other insurance types. Males were less likely to present with early-stage disease, pre- or post-ACA. CONCLUSIONS: We demonstrate a significant association between ACA implementation and increased early-stage presentation among Medicaid-enrolled HNC patients. This suggests that coverage expansions through the ACA may be associated with increased access to care and may yield greater benefits among low-income HNC patients.

Association of Medicaid Expansion With Insurance Coverage Among Children With Cancer.

Importance: Despite evidence of improved insurance coverage under the Affordable Care Act and Medicaid expansion among adults with cancer, little is known regarding the association of these policies with coverage among children with cancer. Objective: To assess the association of early Medicaid expansion with rates of Medicaid coverage, private coverage, and no uninsurance among children with cancer. Design, Setting, and Participants: This cross-sectional study used data from the Surveillance, Epidemiology, and End Results (SEER) database from January 1, 2007, to December 31, 2015, to identify children diagnosed with cancer at ages 0 to 14 years in the United States. Data were analyzed from July 27, 2017, to October 7, 2019. Exposures: Changes in insurance status at diagnosis after early Medicaid expansion in California, Connecticut, Washington, and New Jersey (EXP states) were compared with changes in nonexpansion (NEXP) states (Arkansas, Georgia, Hawaii, Iowa, Kentucky, Louisiana, Michigan, New Mexico, and Utah). Main Outcomes and Measures: Difference-in-differences (DID) analyses were used to compare absolute changes in insurance status (uninsured, Medicaid, private/other) at diagnosis before (2007 to 2009) and after (2011 to 2015) expansion in EXP relative to NEXP states. Results: A total of 21 069 children (11 265 [53.5%] male; mean [SD] age, 6.18 [4.57] years) were included. A 5.25% increase (95% CI, 2.61%-7.89%; P < .001) in Medicaid coverage in children with cancer was observed in EXP vs NEXP states, with larger increases among children of counties with middle to high (adjusted DID estimates, 10.18%; 95% CI, 4.22%-16.14%; P = .005) and high (adjusted DID estimates, 6.13%; 95% CI, 1.10%-11.15%; P = .05) poverty levels (P = .04 for interaction). Expansion-associated reductions of children reported as uninsured (-0.73%; 95% CI, -1.49% to 0.03%; P = .06) and with private or other insurance (-4.52%; 95% CI, -7.16% to -1.88%; P < .001) were observed. For the latter, the decrease was greater for children from counties with middle to high poverty (-9.00%; 95% CI, -14.98% to -3.02%) and high poverty (-6.38%; 95% CI, -11.36% to -1.40%) (P = .04 for interaction). Conclusions and Relevance: In this study, state Medicaid expansions were associated with increased Medicaid coverage in children with cancer overall and in some subgroups primarily owing to switching from private coverage, particularly in counties with higher levels of poverty but also through reductions in the uninsured.

Impact of the Patient Protection and Affordable Care Act on cost-related medication underuse in nonelderly adult cancer survivors.

BACKGROUND: Cost-related medication underuse (CRMU), a measure of access to care and financial burden, is prevalent among cancer survivors. The authors quantified the impact of the Patient Protection and Affordable Care Act (ACA) on CRMU in nonelderly cancer survivors. METHODS: Using National Health Interview Survey data (2011-2017) for cancer survivors aged 18 to 74 years, the authors estimated changes in CRMU (defined as taking medication less than prescribed due to costs) before (2011-2013) to after (2015-2017) implementation of the ACA. Difference-in-differences (DID) analyses estimated changes in CRMU after implementation of the ACA in low-income versus high-income cancer survivors, and nonelderly versus elderly cancer survivors. RESULTS: A total of 6176 cancer survivors aged 18 to 64 years and 4100 cancer survivors aged 65 to 74 years were identified. In DID analyses, there was an 8.33-percentage point (PP) (95% confidence interval, 3.06-13.6 PP; P = .002) decrease in CRMU for cancer survivors aged 18 to 64 years with income <250% of the federal poverty level (FPL) compared with those with income >400% of the FPL. There was a reduction for cancer survivors aged 55 to 64 years compared with those aged 65 to 74 years with income <400% of the FPL (-9.35 PP; 95% confidence interval, -15.6 to -3.14 PP [P = .003]). CONCLUSIONS: There was an ACA-associated reduction in CRMU noted among low-income, nonelderly cancer survivors. The ACA may improve health care access and affordability in this vulnerable population.

Associations of Early Medicaid Expansion With Insurance Status and Stage at Diagnosis Among Cancer Patients Receiving Radiation Therapy.

PURPOSE: Medicaid expansion in 2014 is associated with improved insurance coverage and stage at diagnosis in cancer patients. However, little is known about the effect of early Medicaid expansions in 2010 to 2011 on outcomes in radiation therapy recipients. The objective of this study was to estimate the effect of early Medicaid expansion on insurance status and stage at diagnosis among radiation therapy recipients. METHODS AND MATERIALS: The Surveillance, Epidemiology, and End Results database was queried for cases aged 18 to 64 diagnosed in 2007 to 2013 with a first primary malignancy treated with radiation therapy. Difference-in-differences analyses were used to compare changes in insurance coverage and stage at diagnosis from 2007 to 2009 and 2011 to 2013 in expansion relative to nonexpansion states. RESULTS: There was a -0.48 (95% confidence interval [CI], -0.84 to -0.13; P = .007) percentage point (PP) reduction in uninsured in expansion relative to nonexpansion states, primarily among counties with lower educational attainment (-1.73 PP; 95% CI, -2.72 to -0.75). Increases in early stage diagnoses in expansion relative to nonexpansion states were found overall and in breast (1.56 PP; 95% CI, 0.45-2.68; P = .006), colorectal (3.72 PP; 95% CI, 0.33-7.12; P = .032), and lung (1.49 PP; 95% CI, 0.25-2.72; P = .018) cancers. Decreases in late stage diagnoses were found in cervical (-5.91 PP; 95% CI, -9.58 to -2.25; P = .002), colorectal (-2.72 PP; 95% CI, -5.43 to -0.01; P = .05), and lung (-3.28 PP; 95% CI, -5.47 to -1.1; P = .003) cancers. CONCLUSIONS: For radiation therapy recipients, early Medicaid expansion was associated with decreased percent uninsured, particularly among low education counties, and earlier stage diagnoses for screenable cancers. Thus, early Medicaid expansion may improve access to care and decrease disparities for radiation therapy recipients.

Impact of the affordable care act dependent coverage provision on young adult cancer patient insurance coverage by sociodemographic and economic characteristics.

PURPOSE: To evaluate the impact of the Affordable Care Act Dependent Care Provision by sociodemographic and economic characteristics in young adult cancer patients. METHODS: The National Cancer Database (NCDB) and the Surveillance, Epidemiology, and End Results (SEER) 18 database were queried for young adult cancer cases diagnosed during 2007-2014. Using a difference-in-differences approach, we examined insurance coverage in different subgroups of policy-eligible 19-25 year-olds versus policy-ineligible 27-29 year-olds from the pre- (2007-2009) to post- (2011-2014) Dependent Care Provision period. RESULTS: Across subgroups and study populations, insurance coverage increased significantly following the Provision enactment in the policy-eligible versus policy-ineligible group across most subgroups (range in NCDB: 1.83 to 6.38% for low and mid-low education areas, respectively; range in SEER: 1.43 to 6.18 for Non-Hispanic Others and Hispanics, respectively). Heterogenous impacts were observed by sex with a larger impact in males (NCDB: 5.14%, 95% CI 3.59-6.69; SEER: 4.46, 2.12-6.8) than females (NCDB: 2.51%, 95% CI 1.39-3.62; SEER: 2.50, 0.82-4.18). We observed no other statistical evidence for Dependent Care Provision subgroup heterogeneity except for a smaller impact in individuals from low education areas in NCDB. CONCLUSIONS: Our results indicate a positive Dependent Care Provision impact on insurance coverage in young adults with cancer across subgroups, with evidence for a smaller impact in females relative to males and in low relative to high education areas.