Association of State-level Medicaid Expansion, Prostate Cancer Incidence and Insurance Status: A Multivariable Logistic and Joinpoint Regression Analysis, SEER 2012–2014 Open Access

Abstract

Introduction

 

The Affordable Care Act (ACA) expanded health insurance coverage in the United States in multiple ways, including through voluntary state-based provision of Medicaid. We evaluated the association between Medicaid expansion and prostate cancer incidence, hypothesizing that increased access would be associated with increased prostate cancer incidence.

 

Methods

 

Using data from the Surveillance Epidemiology and End Results (SEER) program (2012–2014), we identified men 40+ years of age newly-diagnosed with prostate cancer. We determined quarterly prostate cancer incidence and compared this outcome between states that did and did not expand Medicaid coverage. Using joinpoint regression, we estimated trends in age-adjusted prostate cancer incidence and examined annual percent change (APC) over time by stage of disease. We also generated a multivariable model which adjusted for patient-level sociodemographic factors and estimated individual-level odds of prostate cancer diagnosis based on residence in a Medicaid expansion state.

 

Results

 

We identified 142,082 prostate cancer patients (mean age 66.1±9.0 years) diagnosed between January 1, 2012 and December 31, 2014. In non-expansion states, more men were Black (31.0% vs. 11.0%), uninsured (2.3% vs. 1.3%), and less commonly covered by Medicaid (4.5% vs. 5.2%) (all p<0.001). In 2014, residence in an expansion state was associated with increased likelihood of Medicaid coverage (RR 1.20, 95% CI 1.14–1.27) and lower odds of being uninsured (OR 0.48, 95% CI 0.43–0.54). Overall prostate cancer incidence decreased over time (APC -0.80%) in non-expansion states. In men ages 40-64 years, overall prostate cancer incidence decreased in both expansion and non-expansion states (APC -0.83% expansion states, -0.53% non-expansion) (both p < 0.001). We did not observe a clear relationship between Medicaid expansion and changes in incidence of prostate cancer across all stages. There was a monotonic decrease in localized disease of -0.54% to -0.40% interrupted by a sharper decline from June–September 2013 (APC -4.34%). Incidence of nodal disease increased (APC 0.68%) while regional and metastatic disease incidence remained relatively unchanged (APC -0.34%, 0.10%, respectively).

 

Conclusions

 

Despite increased Medicaid coverage, trends in prostate cancer incidence do not appear to be influenced by Medicaid expansion, though effects of Medicaid expansion may be delayed beyond one year.

Table of Contents

Introduction..........................................................................................................................1

Methods............................................................................................................................... 3

Study Population........................................................................................................... 3

Statistical Analysis........................................................................................................ 4

Results.................................................................................................................................   6

      Incidence Rates: Joinpoint Regression.......................................................................... 6

      Association of Medicaid Expansion and Insurance Status: Multivariable Analysis..... 8

Discussion.......................................................................................................................... 10

Conclusions........................................................................................................................ 14

References.......................................................................................................................... 15

Tables................................................................................................................................. 20

Figures................................................................................................................................ 23

Supplementary Tables........................................................................................................ 26

 

About this Master's Thesis

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School	Rollins School of Public Health
Department	Epidemiology
Subfield / Discipline	Epidemiology - MPH & MSPH
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health Health Sciences, Epidemiology Health Sciences, Surgery
Keyword	Prostate cancer SEER Urology Medicaid
Committee Chair / Thesis Advisor	Filson, Christopher P., Emory University Goodman, Michael, Emory University
Partnering Agencies	Emory University schools, faculty or affiliated programs

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