Changes in insurance coverage for cancer patients receiving brachytherapy before and after enactment of the Affordable Care Act.

Purpose: The Patient Protection and Affordable Care Act called for expansion of Medicaid in 2014. As some states elected to expand Medicaid and others did not, the goal of this study was to determine the effect of Medicaid expansion on the insurance status at cancer diagnosis of brachytherapy patients.

Methods And Materials: Patients aged 19-64 years with breast, cervical, uterine, or prostate cancer treated with brachytherapy from 2011 to 2014 with known insurance status were identified within the Surveillance, Epidemiology, and End Results registry. Fisher's exact test was used to test for associations of insurance status with expanded versus nonexpanded states. For multivariate analysis, a binomial logistic regression was performed, dichotomized to uninsured versus any insurance.

Results: Fifteen thousand four hundred ninety-seven subjects met entry criteria. In the entire cohort, rates of uninsurance were higher in nonexpanded states at baseline (4.5% vs. 2.9%, p < 0.00001). With selective Medicaid expansion in 2014, expanded states had a reduction in uninsurance rates (2.9-1.8%, p = 0.026), whereas nonexpanded states had a nonsignificant increase in uninsurance (4.5-5.0%, p = 0.371). There was a reduction in uninsurance in expanded states in areas of highest poverty (2.9-1.1%, p = 0.0004) not seen in nonexpanded states. These associations remained significant on multivariate analysis (OR 2.2, 95% CI 1.8-2.8, p < 0.00001).

Conclusions: Patients who received brachytherapy were less likely to be uninsured in states where Medicaid was expanded, particularly evident in regions with highest poverty levels. These results should help inform policy decisions and efforts to ensure that all patients have access to high quality treatments, such as brachytherapy.