The association between the Affordable Care Act on insurance status, cancer stage, and overall survival in patients with renal cell carcinoma.
Authors: Javier-Desloges Juan , Yuan Julia , Soliman Shady , Hakimi Kevin , Meagher Margaret Frances , Ghali Fady , Hsiang Walter , Patel Devin , Murphy James Don , Kim Simon P. , Derweesh Ithaar 
Published: March 2021

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Background: We aimed to determine whether insurance expansions implemented through the Patient Protection and Affordable Care Act (ACA) were associated with changes in insurance coverage status, stage at diagnosis, and overall survival for patients with renal cell carcinoma (RCC). Methods: We identified patients 40 to 64 years old diagnosed with RCC between 2010 and 2016 in the National Cancer Database. States were categorized as participating on time in Medicaid expansion or not participating. We stratified patients into advanced cancer (stage III + IV) and localized cancer (stage I + II) groups. We stratified patients into low, middle, and high income groups. Stage trend and insurance trend analysis were performed to based on income status amongst patients living in expansion and non-expansion states. Absolute percentage change (APC) was calculated for insurance status and stage migration. Cox Regression Multivariable Analysis was conducted to assess risk of all-cause mortality (ACM) for patients before and after the implementation of the ACA, adjusting for insurance status, income, education, age, race, ethnicity, comorbidity, and living in an expansion state. Results: We identified 78,099 patients who met inclusion criteria. Following implementation of ACA, APC of patients with insurance increased in both Medicaid and non-expansion states by 4.0% and 2.10% (p<0.01), respectively. The largest increases occurred in expansion states, with low income patients acquiring Medicaid (APC +11.0% p<0.01), middle income patients acquiring Medicaid (APC +8.20% p<0.01), and high-income patients acquiring Medicaid (APC +4.0% p<0.01). In our stage trend analysis, there was a higher proportion of patients with localized stage disease after the implementation of the ACA in low income (APC +4.0% p<0.01) and middle-income patients (APC +1.6% p=0.02.) who live in expansions states, as well as middle income patients in non-expansions states (APC 1.4% p=0.02). Cox Regression MVA revealed that before ACA implementation, low income and middle income were associated with higher risk of mortality (HR 1.29 95%CI 1.18-1.40 p<0.01) and (HR 1.18 95% CI 1.10-1.26, p<0.01, but was not following ACA implementation (p=0.20) and (p=0.05) respectively. Conclusions: Following the implementation of the ACA the proportion of patients with newly diagnosed RCC with health insurance increased with the largest effects seen in Medicaid expansions states. In addition, higher proportions of patients were diagnosed with localized disease in Medicaid expansion states amongst low- and middle-income patients. Furthermore, income status ceased being a risk factor for mortality following ACA implementation. Our findings suggest that ACA implementation has been associated with downward stage migration in low/middle-income patients and attenuation of income status as a risk for mortality in RCC.