Health Care Disparities in Cancer Patients Receiving Radiation: Changes in Insurance Status After Medicaid Expansion Under the Affordable Care Act

Purpose: To compare insurance status in cancer patients receiving radiation before and after Medicaid expansion under the Patient Protection and Affordable Care Act (ACA), in both expanded and non-expanded states. Methods and Materials: Newly diagnosed cancer patients aged 18 to 64 years who received radiation from 2011 to 2014 were compiled from the Surveillance, Epidemiology, and End Results database. Patients with a prior cancer diagnosis or unknown insurance status were excluded. Insurance rates at diagnosis were examined before (2011-2013) and after Medicaid expansion (2014) and compared between states that fully or did not fully expand Medicaid. Results: A total of 197,290 patients were analyzed. Of these, 73% lived in expanded states. After expansion, there was a 53% relative decrease in uninsured rates in expanded states (4.3%-2.1%) and a 5% relative decrease in non-expanded states (8.4%-8.0%) (P<.0001). In expanded states, the uninsured rate decreased regardless of race (whites: relative decrease 56%, 4.3% to 1.9%; blacks: relative decrease 50%, 6.0 to 3.0%; both P<.0001) or county poverty level (low poverty: relative decrease 46%, 3.9% to 2.1%; high poverty: relative decrease 60%, 4.5% to 1.8%; both P<.0001). In non-expanded states, a decrease in uninsured levels was seen primarily in whites (relative decrease 9%, 7.8% to 7.1%, P<.0001; blacks: relative increase 7%, 9.9% to 10.6%, P = .37) and those living in areas with the lowest poverty (relative decrease 27%, 4.8% to 3.5%, P = .04; high poverty: relative increase 2%, 10.9% to 11.1%, P = .17). Blacks and those living in the highest poverty areas had the greatest level of benefit from full expansion (absolute benefit 2.0%-2.3%, P = .0093 and P = .0029, respectively). Conclusions: Medicaid expansion in 2014 significantly decreased uninsured rates for cancer patients receiving radiation. Full expansion decreased rates of uninsurance to a greater degree and seemed to decrease racial and economic disparities. (C) 2017 Elsevier Inc. All rights reserved.