Hsiang Walter, Han Xuesong, Jemal Ahmedin, Nguyen Kevin A, Shuch Brian, Park Henry, Yu James B, Gross Cary P, Davidoff Amy J, Leapman Michael S
Yale University School of Medicine.
Surveillance and Health Services Research Program, Department of Intramural Research, American Cancer Society, Atlanta, Georgia.
Urol Pract. 2020 Jul;7(4):252-258. doi: 10.1097/upj.0000000000000109. Epub 2020 Jul 1.
We aimed to determine whether insurance expansions implemented through the Affordable Care Act (ACA) were associated with changes in coverage status, disease stage, and treatment of younger adults with testicular germ cell tumors (GCT).
We identified men aged 18-64 diagnosed with testicular GCTs between 2010 and 2015 in the National Cancer Data Base. We defined time periods as: pre-ACA (2010-2013) and post-ACA (2014-2015) and used difference-in-differences (DID) modeling to examine associations between state Medicaid expansion status and changes in insurance, stage at diagnosis, and treatment.
Following the ACA, the proportion of patients with any health insurance increased 3.7% (95% CI 3-4.5) in Medicaid expansion states and 3.0% (95% CI 1.5-4.5) in non-expansion states, mainly by gaining Medicaid and private insurance, respectively. The largest increases occurred in low-income patients, where Medicaid expansion was associated with an adjusted increase of 14.5 percentage points (95% CI 7.2-21.8) in Medicaid coverage following the ACA. We did not observe reductions in late-stage diagnoses during the observation period. Changes in the proportion of patients receiving chemotherapy or radiation for advanced-stage cancers were ongoing prior to the ACA and differed between expansion and non-expansion states, limiting assessment of ACA-related effects on individual treatments.
Post-ACA, the proportion of newly diagnosed testicular cancer patients with health insurance increased, with the largest effects seen among lowest income individuals. Our findings that changes in practice preceded the ACA and differed by expansion status highlight the need for caution in assessing the legislation's impact.
我们旨在确定通过《平价医疗法案》（ACA）实施的保险扩展是否与年轻睾丸生殖细胞肿瘤（GCT）患者的覆盖状态、疾病分期和治疗变化相关。
我们在国家癌症数据库中识别出2010年至2015年间诊断为睾丸GCT的18 - 64岁男性。我们将时间段定义为：ACA之前（2010 - 2013年）和ACA之后（2014 - 2015年），并使用差异-in-差异（DID）模型来研究州医疗补助扩展状态与保险、诊断分期和治疗变化之间的关联。
ACA实施后，医疗补助扩展州有任何医疗保险的患者比例增加了3.7%（95%置信区间3 - 4.5），非扩展州增加了3.0%（95%置信区间1.5 - 4.5），主要分别是通过获得医疗补助和私人保险。最大的增幅出现在低收入患者中，ACA实施后，医疗补助扩展与医疗补助覆盖调整后增加14.5个百分点（95%置信区间7.2 - 21.8）相关。在观察期内，我们未观察到晚期诊断的减少。对于晚期癌症接受化疗或放疗的患者比例变化在ACA之前就已存在，且扩展州和非扩展州有所不同，这限制了对ACA对个体治疗相关影响的评估。
ACA实施后，新诊断的睾丸癌患者中有医疗保险的比例增加，在最低收入个体中影响最大。我们的研究结果表明，实践变化先于ACA且因扩展状态而异，这凸显了在评估该立法影响时需谨慎的必要性。
