Elderly adults with cancer and the potential role of Medicaid expansion

Purpose: Medicaid expansion under the Affordable Care Act, which increased Medicaid eligibility limits for non-elderly (age < 65 years) adults in states electing to expand, has been associated with improved access to care and outcomes among non-elderly adults with cancer. While the expansions did not directly affect insurance eligibility for elderly individuals, elderly adults comprise over 50% of new cancer diagnoses, and data from the general USA population suggests that the effects of Medicaid expansion may have spilled over to elderly individuals. Since the associations between Medicaid expansion and insurance coverage and stage at diagnosis for elderly patients with cancer are unknown, our purpose was to quantify these associations.

Methodology: The Surveillance, Epidemiology, and End Results program was queried for individuals age ≥ 65 years diagnosed with cancer from 2011-2016. Difference-in-differences analyses assessed changes in insurance coverage (% uninsured, % Medicaid) and early stage (stage 1) diagnoses from pre- (2011-2013) to post-Medicaid expansion (2014-2016) in Medicaid expansion vs. non-expansion states. Analyses were adjusted for age, race, sex, race/ethnicity, marital status, county-level education and income, metropolitan residence status, and cancer site. Subgroup analyses by race/ethnicity and cancer site were conducted.

Results: The sample consisted of 683,206 elderly individuals with cancer. In difference-in-differences analyses, there was a reduction in the uninsured rate (-0.13 percentage points, 95% CI = -0.24 to -0.02, p=.018) but no significant increase in Medicaid coverage (0.14 percentage points, 95% CI = -0.18 to 0.46, p=.408) or early stage diagnoses (0.46 percentage points, 95% CI = -0.08 to 0.99, p=.09). In subgroup analyses, Black individuals had the largest expansion-associated decrease in the uninsured rate (-0.41 percentage points, 95% CI = -0.76 to -0.05, p=.024; in contrast, White individuals: -0.02, 95% CI = -0.11 to 0.08, p=.72) and increase in Medicaid coverage (2.08 percentage points, 95% CI = 0.96 to 3.19, p<.001; in contrast, White individuals: 0.2, 95% CI = -0.1 to 0.5, p=.20). There were expansion-associated increases in early stage diagnoses of colorectal cancer (1.65 percentage points, 95% CI = 0.0 to 3.30, p=.050).

Conclusions: Medicaid expansion was associated with improved insurance coverage among elderly individuals with cancer. As Medicaid expansion did not directly target elderly individuals, the improvements may reflect streamlined state marketplaces in expansion states that assess for Medicaid eligibility upon application for health insurance (“no wrong door” policy), enrollment among previously eligible but unenrolled individuals (“welcome mat” effects), or increased awareness or decreased stigma of public health insurance. There were expansion-associated increases in early stage colorectal cancer diagnoses, though future data will shed light on outcomes. The data also suggest narrowing of the Black-White insurance coverage disparity, but the concentration of Black individuals in states that have not expanded Medicaid highlights the need for further advocacy to realize such improvements.

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