SUO 2017: The Impact of The Affordable Care Act and Medicaid Expansion on Insurance Status and Cancer Staging for Bladder Cancer Patients

Washington, DC ( With the introduction of the Affordable Care Act (ACA), many more Americans have obtained access to health insurance. Often patients that were uninsured and without regular healthcare, it is unclear what the impact of their sudden coverage would have on bladder cancer epidemiology in the United States.

The authors of this study attempted to answer that using the National Cancer Database (NCDB) over a 10-year period (2004-2014). As the ACA was passed in 2009, the patients were split into two groups: pre-ACA (2004-2009 diagnosis) and after the Medicaid expansion (2014). While looking at the entire cohort (National) primarily, the authors also separately analyzed the Pacific (PR) subset and West South-central subset (WSC), as these regions represented early Medicaid expanding and non-Medicaid expanding states, respectively. 

Of the 239,479 people diagnosed with BCa in the United States during that time frame, 26,439 were located in the PR, and 13,752 in the WSC. 

Prior to the Medicaid expansion (2004-2009), patients without insurance were at significantly higher risk to present with stage IV BCa, and at even higher risk if they had Medicaid, in all three study groups (OR uninsured: Nationally 1.9 (p<0.001 (CI 1.7-2.1)), PR 1.6 (p=0.012 (CI 1.1-2.2)), WSC 1.8 (p<0.001 CI 1.3-2.5); Medicaid: Nationally 2.3 (p<0.001 (2.1-2.5), PR 2.2 (p<0.001 CI 1.7-2.7), WSC 2.6 (p<0.001 CI 1.8-3.7)).

Following Medicaid expansion, the risk remained elevated for both these groups nationally, but did decrease (OR uninsured 1.6 (p<0.001 CI 1.3-2.1), Medicaid 1.6 (p<0.001 1.4-1.9)). 

In the PR subset, patients without insurance had no significantly different risk compared to their privately insured peers post-expansion, but those with Medicaid had a persistent elevated risk (OR 2.2 (p=0.001 CI 1.4-3.4)). On the other hand, in the WSC, patients without insurance had an increased risk of stage IV disease (OR 2.2 (p=0.007 CI 1.2-3.9)), but those with Medicaid had no significantly different risk than their privately insured peers post-expansion. 

Based on this, the authors noted that while prior to the ACA, patients without insurance and those on Medicaid were more likely to present with stage IV BCa than their privately insured peers, in the first year following expansion, these odds improved nationally for those without insurance and Medicaid. However, states with expansions did not see this improvement in their Medicaid population, while non-expanded states did.

It is unclear what this study adds to the discussion. Further analysis on the implications to the system and recommendations regarding moving forward would have been more useful.

Also, it is unclear how well the NCDM captures insurance status. As many patients may have multiple insurance coverage, it is possible there may be some overlap. 

Presented by: Kyle P. Plante, MS, MPH

Co- Authors: Natasha Ginzburg MD, Oleg Shapiro MD, Joseph Jacob MD, Gennady Bratslavsky MD and Elizabeth Ferry MD
Affiliation: SUNY Upstate Medical University, Syracuse, NY

Written by: Thenappan Chandrasekar, MD, Clinical Fellow, University of Toronto, twitter: @tchandra_uromd at the 18th Annual Meeting of the Society of Urologic Oncology, November 20-December 1, 2017 – Washington, DC