平价医疗法案下医疗补助扩大与新诊断癌症患者生存状况的关联。
Association Between Medicaid Expansion Under the Affordable Care Act and Survival Among Newly Diagnosed Cancer Patients.
机构信息
Surveillance & Health Equity Science, American Cancer Society, Atlanta, GA, USA.
Cancer Data Registry of Idaho, Boise, ID, USA.
出版信息
J Natl Cancer Inst. 2022 Aug 8;114(8):1176-1185. doi: 10.1093/jnci/djac077.
BACKGROUND
Medicaid expansion under the Affordable Care Act (ACA) is associated with increased insurance coverage among patients with cancer. Whether these gains translate to improved survival is largely unknown. This study examines changes in 2-year survival among patients newly diagnosed with cancer following the ACA Medicaid expansion.
METHODS
Patients aged 18-62 years from 42 states' population-based cancer registries diagnosed pre (2010-2012) and post (2014-2016) ACA Medicaid expansion were followed through September 30, 2013, and December 31, 2017, respectively. Difference-in-differences (DD) analysis of 2-year overall survival was stratified by sex, race and ethnicity, census tract-level poverty, and rurality.
RESULTS
A total of 2 555 302 patients diagnosed with cancer were included from Medicaid expansion (n = 1 523 585) and nonexpansion (n = 1 031 717) states. The 2-year overall survival increased from 80.58% pre-ACA to 82.23% post-ACA in expansion states and from 78.71% to 80.04% in nonexpansion states, resulting in a net increase of 0.44 percentage points (ppt) (95% confidence interval [CI] = 0.24ppt to 0.64ppt) in expansion states after adjusting for sociodemographic factors. By cancer site, the net increase was greater for colorectal cancer (DD = 0.90ppt, 95% CI = 0.19ppt to 1.60ppt), lung cancer (DD = 1.29ppt, 95% CI = 0.50ppt to 2.08ppt), non-Hodgkin lymphoma (DD = 1.07ppt, 95% CI = 0.14ppt to 1.99ppt), pancreatic cancer (DD = 1.80ppt, 95% CI = 0.40ppt to 3.21ppt), and liver cancer (DD = 2.57ppt, 95% CI = 1.00ppt to 4.15ppt). The improvement in 2-year overall survival was larger among non-Hispanic Black patients (DD = 0.72ppt, 95% CI = 0.12ppt to 1.31ppt) and patients residing in rural areas (DD = 1.48ppt, 95% CI= -0.26ppt to 3.23ppt), leading to narrowing survival disparities by race and rurality.
CONCLUSIONS
Medicaid expansion was associated with greater increase in 2-year overall survival, and the increase was prominent among non-Hispanic Blacks and in rural areas, highlighting the role of Medicaid expansion in reducing health disparities. Future studies should monitor changes in longer-term health outcomes following the ACA.
背景
平价医疗法案（ACA）下的医疗补助计划扩大覆盖范围与癌症患者的保险覆盖范围增加有关。这些收益是否转化为生存改善，在很大程度上尚不清楚。本研究考察了 ACA 医疗补助计划扩大覆盖范围后，新诊断癌症患者的两年生存率变化。
方法
42 个州的基于人群的癌症登记处的年龄在 18-62 岁之间的患者在 ACA 医疗补助计划之前（2010-2012 年）和之后（2014-2016 年）被随访，分别随访至 2013 年 9 月 30 日和 2017 年 12 月 31 日。采用差异中的差异（DD）分析方法，对按性别、种族和民族、按普查区贫困程度和农村地区划分的两年总体生存率进行分层。
结果
纳入了来自医疗补助计划扩大（n=1523585）和未扩大（n=1031717）州的共 2555302 名癌症患者。在扩大覆盖范围的州，两年总体生存率从 ACA 前的 80.58%增加到 ACA 后的 82.23%，在未扩大覆盖范围的州，从 78.71%增加到 80.04%，调整社会人口因素后，扩大覆盖范围的州净增 0.44 个百分点（95%置信区间[CI]：0.24 至 0.64）。按癌症部位，结直肠癌（DD=0.90，95%CI：0.19 至 1.60）、肺癌（DD=1.29，95%CI：0.50 至 2.08）、非霍奇金淋巴瘤（DD=1.07，95%CI：0.14 至 1.99）、胰腺癌（DD=1.80，95%CI：0.40 至 3.21）和肝癌（DD=2.57，95%CI：1.00 至 4.15）的两年总体生存率净增加更大。非西班牙裔黑人患者（DD=0.72，95%CI：0.12 至 1.31）和居住在农村地区的患者（DD=1.48，95%CI：-0.26 至 3.23）的两年总体生存率改善更大，导致种族和农村地区的生存差距缩小。
结论
医疗补助计划扩大与两年总体生存率的更大提高有关，非西班牙裔黑人和农村地区的增幅更为显著，这突显了医疗补助计划在减少健康差距方面的作用。未来的研究应监测平价医疗法案后更长期健康结果的变化。
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