Abstract PR09: Racial disparities in health insurance status of U.S. adults with hematologic malignancies in states with and without Medicaid expansion: Analyses from the National Cancer Database, 2007-2016
Authors: Calip Gregory S. , Ko Naomi Y , Sweiss Karen I. , Patel Pritesh R. , Chiu Brian C.-H. 
Published: September 2020

Abstract
Introduction: Lack of health insurance is an important determinant of cancer health disparities in the United States. For patients with hematologic malignancies, breakthroughs in novel chemotherapeutics, targeted therapies, and stem cell transplantation are counterbalanced with concerns for financial toxicity and lack of access without adequate health coverage. Our objective was to measure racial differences in uninsured rates among patients with hematologic malignancies in states with and without Medicaid expansion under the Affordable Care Act.
Methods: We conducted a hospital-based retrospective cohort study of adults aged 40-64 years diagnosed with hematologic malignancies (lymphoma, multiple myeloma, leukemia, and Waldenstrom macroglobulinemia) between 2007 and 2016 using the National Cancer Database (NCDB). We collected information on demographics, clinical characteristics, insurance coverage, socioeconomic factors, and state Medicaid expansion status. We grouped Medicaid expansion states as: (i) non-expansion states, (ii) early expansion states (2010-2013), and (iii) late expansion states (2014-2016). Covariate adjusted difference-in-differences (DID) analyses were performed to determine changes in the percentage of uninsured hematologic malignancy patients over time. In modified Poisson regression models, we calculated adjusted rate ratios (RR) and 95% confidence intervals to identify disparities in uninsured rates among black, Hispanic, and Asian/Pacific Islander (API) patients compared to white patients by time period and Medicaid expansion.
Results: An overall cohort of 338,353 hematologic malignancy patients (median age: 56 years; 43% female) residing in Medicaid non-expansion (n=124,875), early expansion (n=60,305) and late expansion (n=153,173) states were included. Compared to 2007-2009, the proportion of uninsured patients was lower in 2014-2016 across all states; however, more substantial decreases in percentage uninsured occurred in states with Medicaid expansion (4.9% to 2.5%, diff 2.4%) versus states without expansion (9.4% to 8.3%, diff 1.1%; DID -1.3, P&lt;0.01). These reductions were consistent among white (DID -1.1, P&lt;0.01) and Hispanic (DID -4.3, P&lt;0.01) patients; however, decreases in uninsured rates among black (DID -0.3, P=0.67) and API (DID 1.9, P=0.41) patients were not statistically significant. Regardless of expansion status, racial disparities persisted over time with racial and ethnic minority patients having a 1.5- to 3.0-fold higher likelihood of being uninsured compared to white patients.
Conclusions: Our study found that the proportion of uninsured hematologic malignancy patients in the NCDB decreased between 2007 and 2016, but this reduction was significantly greater in states with Medicaid expansion. We also identified racial disparities where black and API patients experienced minimal decreases attributed to Medicaid expansion and black, Hispanic, and API patients were consistently more likely to be uninsured over time.
This abstract is also being presented as Poster A115.
Citation Format: Gregory S. Calip, Naomi Y Ko, Karen I. Sweiss, Pritesh R. Patel, Brian C.-H. Chiu. Racial disparities in health insurance status of U.S. adults with hematologic malignancies in states with and without Medicaid expansion: Analyses from the National Cancer Database, 2007-2016 [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr PR09.