br Results br Sixteen thousand one hundred thirty four
Sixteen thousand one hundred thirty-four subjects be-tween the ages of 19 and 64 years with newly diagnosed breast, cervical, uterine, or prostate cancer from January 2011 through December 2014 treated with brachytherapy
Included in SEER
American Indian Nations
Included in SEER
Fig. 1. Map showing SEER states plus expanded and nonexpanded states.
were identified. Of these, 15,497 (96%) had known insurance status. The median age of all patients was 58 years (inter-quartile range 52e61 years) and 39.2% were male. About 76% of patients were white and 91.4% were non-Hispanic. At the time of diagnosis, 1028 patients were uninsured, whereas 29,966 had either Medicaid or non-Medicaid insur-ance. At the time of diagnosis, 66.5% of patients lived in expanded states. Patient characteristics stratified by expanded versus nonexpanded states are shown in Table 1.
Patients with cervical, uterine, or prostate cancer living in expanded states all experienced significant decreases in uninsurance rates after Medicaid expansion when examined together. Patients with cervical cancer had an absolute decrease in uninsurance rates of 3% (7.7e4.7%, p 5 0.012) in expanded states after Medicaid expansion. For pa-tients with uterine cancer, there was a decrease from 3.4% to 1.6% in uninsurance rates in expanded states, p 5 0.006. In prostate cancer, the decrease in uninsurance was small, but statistically significant; more pronounced was the in-crease in Medicaid insurance (3.5e7.4%, p 5 0.0003). Pa-tients with breast cancer in expanded states had a cck8 in uninsurance rates, but this change was not significant. There were no significant uninsurance changes in the non-expanded states for any diagnosis.
Stratified by poverty level, all patients in expanded states had decreases in uninsurance rates after Medicaid expansion, although differences were only significant in patients in the first quartile (lowest poverty level), third quartile, and fourth quartile (highest poverty level). For patients in nonexpanded
Demographics and clinical characteristics stratified by expanded versus nonexpanded states
Characteristic n (%)
Unmarried/domestic partner 47 (0.5)
Insurance status at cancer diagnosis
Year of diagnosis
Percent living below the poverty levelc
IQR 5 interquartile range.
a Expanded states are defined as states which have fully expanded Medicaid as of January 1, 2014; within the SEER database this is CA, CT, HI, KY, MI, NJ, NM, WA. b Nonexpanded states are defined as states which have not fully expanded Medicaid; within the SEER database this is AK, GA, IA, LA, UT.
c Calculated from census data representing the percent of residents in the county of patient residence living below the poverty level; quartile 1 11.7%, median 14.7%, quartile 3 18.4%. d Denotes significant result.
states, there were no significant changes in insurance rates regardless of poverty level after Medicaid expansion. Nonex-panded states actually experienced a nonsignificant trend to-ward an increase in uninsurance from 5.0% to 6.3% in the poorest quartile of patients, p 50.054 (Table 2). On multivar-iate analysis, increasing percent below poverty level was a significant predictor of uninsurance (OR 1.047 per %, 95% CI 1.015e1.080, p 5 0.0046) (Table 4).
In this retrospective SEER analysis examining changes in insurance status in patients treated with brachytherapy, pa-tients living in expanded states were more likely to be insured after Medicaid expansion in 2014. Patients in areas of the highest poverty had a significant reduction in uninsurance rates in expanded states, consistent with the goals of the
ACA. There was a nonsignificant increase in levels of unin-surance in the highest poverty quartile in nonexpanded states after 2014, exacerbating challenges for cancer patients at highest risk for health care disparities (10e12).
Although the ACA was passed in March of 2010, the greatest decline in rates of uninsurance in the United States was not realized until January 2014, when policies to allow more inclusive coverage were enacted. These included a ban on preexisting condition exclusion, health insurance exchanges, individual subsidies, and the expansion of Medicaid. This present study, along with other recently published data, suggest that the most significant impact on the decline in uninsurance rates is likely attributed to the expansion of Medicaid (10, 11).
The Institute of Medicine published a report in 2002 de-tailing the connection between uninsurance and decreased access to recommended care, receipt of poorer quality of care, and worse health outcomes as compared with insured
Insurance status and type before and after Medicaid expansion