Presentation Authors: Walter Hsiang, New Haven, CT, Ahmedin Jemal, Atlanta, GA, Kevin Nguyen, Brian Shuch, Los Angeles, CA, Henry Park, James Yu, Cary Gross, Amy Davidoff, Michael Leapman*, New Haven, CT
Introduction: Young adults are historically the least likely to have health insurance in the United States. We aimed to investigate whether implementation of key provisions of the Affordable Care Act (ACA) was associated with insurance status, disease stage, and initial treatment of patients with testicular cancer, a disease primarily diagnosed in younger men.
Methods: We identified men diagnosed with testicular germ cell tumors (GCT) between 2010 and 2015 in the National Cancer Data Base (NCDB). We defined time periods relative to implementation of the ACA provisions: pre-ACA (2010-2013) and post-ACA (2014-2015). Difference-in-differences (DID) modeling was used to examine the associations among state-level Medicaid expansion status and changes in insurance coverage, stage at diagnosis, and treatment. We further stratified analyses by income level relative to federal poverty guidelines.
Results: Among 30,842 patients, the overall proportion with any health insurance increased after implementation of the ACA. Increases were seen in both expansion and non-expansion states, attributable to increases in Medicaid and private insurance, respectively. The largest increases in Medicaid coverage occurred in low-income patients residing in expansion states (increasing from 19.3% to 34.1%; absolute percentage point change (APC) +14.8, 95% CI 9-20.5), in contrast to stability in non-expansion states (12.2% to 10.7%; -1.4 APC, 95% CI -6.2, 3.3), adjusted DID estimate of 14.5% (95% CI, 7.2 to 21.8, p < 0.05). We did not observe reductions in late-stage diagnoses during the time period. Changes in treatment patterns were ongoing prior to the ACA and differed between expansion and non-expansion states. Hence, we were unable to assess ACA-related effects on treatment.
Conclusions: Following the ACA implementation, 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 legislationâ€™s impact in this population.