Section of Surgical Oncology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.
JAMA Surg. 2020 Aug 1;155(8):752-758. doi: 10.1001/jamasurg.2020.1495.
The expansion of Medicaid sought to fill gaps in insurance coverage among low-income Americans. Although coverage has improved, little is known about the relationship between Medicaid expansion and breast cancer stage at diagnosis.
To review the association of Medicaid expansion with breast cancer stage at diagnosis and the disparities associated with insurance status, age, and race/ethnicity.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study used data from the National Cancer Database to characterize the relationship between breast cancer stage and race/ethnicity, age, and insurance status. Data from 2007 to 2016 were obtained, and breast cancer stage trends were assessed. Additionally, preexpansion years (2012-2013) were compared with postexpansion years (2015-2016) to assess Medicaid expansion in 2014. Data were analyzed from August 12, 2019, to January 19, 2020. The cohort included a total of 1 796 902 patients with primary breast cancer who had private insurance, Medicare, or Medicaid or were uninsured across 45 states.
Percent change of uninsured patients with breast cancer and stage at diagnosis, stratified by insurance status, race/ethnicity, age, and state.
This study included a total of 1 796 902 women. Between 2012 and 2016, 71 235 (4.0%) were uninsured or had Medicaid. Among all races/ethnicities, in expansion states, there was a reduction in uninsured patients from 22.6% (4771 of 21 127) to 13.5% (2999 of 22 150) (P < .001), and in nonexpansion states, there was a reduction from 36.5% (5431 of 14 870) to 35.6% (4663 of 13 088) (P = .12). Across all races, there was a reduction in advanced-stage disease from 21.8% (4603 of 21 127) to 19.3% (4280 of 22 150) (P < .001) in expansion states compared with 24.2% (3604 of 14 870) to 23.5% (3072 of 13 088) (P = .14) in nonexpansion states. In African American patients, incidence of advanced disease decreased from 24.6% (1017 of 4136) to 21.6% (920 of 4259) (P < .001) in expansion states and remained at approximately 27% (27.4% [1220 of 4453] to 27.5% [1078 of 3924]; P = .94) in nonexpansion states. Further analysis suggested that the improvement was associated with a reduction in stage 3 diagnoses.
In this cohort study, expansion of Medicaid was associated with a reduced number of uninsured patients and a reduced incidence of advanced-stage breast cancer. African American patients and patients younger than 50 years experienced particular benefit. These data suggest that increasing access to health care resources may alter the distribution of breast cancer stage at diagnosis.
重要性：医疗补助计划的扩张旨在填补美国低收入人群的保险覆盖缺口。尽管保险范围有所扩大，但对于医疗补助计划的扩张与乳腺癌诊断时的分期之间的关系知之甚少。
目的：回顾医疗补助计划的扩张与乳腺癌诊断时的分期之间的关系，以及与保险状况、年龄和种族/族裔相关的差异。
设计、设置和参与者：本队列研究使用国家癌症数据库的数据，对乳腺癌分期与种族/族裔、年龄和保险状况之间的关系进行了描述。获取了 2007 年至 2016 年的数据，并评估了乳腺癌分期趋势。此外，比较了 2012-2013 年的预扩张年和 2015-2016 年的后扩张年，以评估 2014 年的医疗补助计划扩张情况。数据分析时间为 2019 年 8 月 12 日至 2020 年 1 月 19 日。该队列包括来自 45 个州的共 1796902 名患有原发性乳腺癌且具有私人保险、医疗保险或医疗补助或无保险的患者。
主要结果和测量：按保险状况、种族/族裔、年龄和州划分的乳腺癌患者和诊断时分期的未参保患者的百分比变化。
结果：本研究共纳入 1796902 名女性。2012 年至 2016 年间，71235 名（4.0%）为无保险或拥有医疗补助。在所有种族/族裔中，在扩张州，未参保患者从 22.6%（21127 人中有 4771 人）降至 13.5%（22150 人中有 2999 人）（P <.001），而在非扩张州，未参保患者从 36.5%（14870 人中有 5431 人）降至 35.6%（13088 人中有 4663 人）（P =.12）。在所有种族中，与非扩张州相比，扩张州的晚期疾病从 21.8%（21127 人中有 4603 人）降至 19.3%（22150 人中有 4280 人）（P <.001），而在非扩张州，从 24.2%（14870 人中有 3604 人）降至 23.5%（13088 人中有 3072 人）（P =.14）。在非裔美国患者中，晚期疾病的发病率从 24.6%（4136 人中有 1017 人）降至 21.6%（4259 人中有 920 人）（P <.001），而在非扩张州则保持在约 27%（27.4%[4453 人中有 1220 人]至 27.5%[3924 人中有 1078 人]；P =.94）。进一步的分析表明，这种改善与 3 期诊断的减少有关。
结论和相关性：在本队列研究中，医疗补助计划的扩张与未参保患者人数的减少和乳腺癌晚期病例的发病率降低有关。非裔美国患者和年龄小于 50 岁的患者尤其受益。这些数据表明，增加获得医疗保健资源的机会可能会改变乳腺癌诊断时的分期分布。
