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Hsiang W, Han X, Jemal A, Nguyen KA, Shuch B, Park H, Yu JB, Gross CP, Davidoff AJ, Leapman MS. The Association Between the Affordable Care Act and Insurance Status, Stage and Treatment in Patients with Testicular Cancer. Urology practice. 2020 Jul 1; 7(4):252-258.
Introduction: We determined whether insurance expansions implemented through the Patient Protection and Affordable Care Act were associated with changes in coverage status, disease stage and treatment of younger adults with testicular germ cell tumors. Methods: We identified men 18 to 64 years old diagnosed with testicular germ cell tumors between 2010 and 2015 in the National Cancer Database. We defined time periods as pre-Affordable Care Act (2010 to 2013) and post-Affordable Care Act (2014 to 2015), and used difference in differences modeling to examine associations between state Medicaid expansion status and changes in insurance, stage at diagnosis and treatment. Results: Following the Affordable Care Act the proportion of patients with any health insurance increased 3.7% (95% CI 3-4.5) in Medicaid expansion states and 3.0% (95% CI 1.5-4.5) in nonexpansion states mainly by gaining Medicaid and private insurance, respectively. The largest increases occurred among low income patients whose Medicaid expansion was associated with an adjusted increase of 14.5% (95% CI 7.2-21.8) in Medicaid coverage following the Affordable Care Act. We did not observe reductions in late stage diagnoses during the observation period. Changes in the proportion of patients receiving chemotherapy or radiation for advanced stage cancers were ongoing before the Affordable Care Act and differed between expansion and nonexpansion states, limiting assessment of Affordable Care Act related effects on individual treatments. Conclusions: Following the Affordable Care Act the proportion of patients with newly diagnosed testicular cancer with health insurance increased with the largest effects seen among the lowest income individuals. Our findings that changes in practice preceded the Affordable Care Act and differed by expansion status highlight the need for caution in assessing the legislation's impact.