Under the ACA, patients with HIV in Medicaid expansion states have greater access to care.
After the Affordable Care Act (ACA) was signed into law in 2010 by then President Barack Obama, the numbers of uninsured adults in the United States fell dramatically. This was aided, in particular, by Medicaid expansion and the elimination of the preexisting condition exclusion.
The effects of this law are seen especially among patients with cancer, who are shown to have better access to care and lower out-of-pocket costs in Medicaid expansion states, according to the results of a recent study in Cancer, the official journal of the American Cancer Society. There is one group of patients with cancer, however, on whom the effects of the ACA are less certain: patients who also have HIV.
According to the authors, “Although the reported effects of the ACA on patients with cancer and patients with HIV have been established separately, to our knowledge little is known regarding the specific impact of the ACA on people living with HIV and cancer.”
Therefore, the researchers set out to compare how insurance coverage and cancer treatment changed—did it improve?—post ACA implementation for people living with HIV and newly diagnosed cancer (PLWHC) in expansion and nonexpansion states. Using the National Cancer Data Base (NCDB) to identify patients aged 18 to 64 years; International Classification of Diseases, Ninth Revision, Clinical Modification codes to determine diagnoses; and primary payer code at diagnosis for insurance status, 4794 patients were included in the study. Because they had reached eligibility for Medicare, patients older than 65 years were excluded. January 2011 to December 2013 was the pre-ACA era and January 2014 to December 2014, post. Twenty-five states chose to expand Medicaid when the ACA took full effect in January 2014. (Today, 37 states have expanded Medicaid.)
Overall, “there was no change noted in the percentage of patients who received cancer treatment post ACA,” the authors noted. However, insurance coverage for PLWHC previously uninsured improved in expansion (from 4.9% to 3%) and nonexpansion states (from 17.6% to 14.6%). In expansion states, Medicaid drove insurance coverage for these patients; private insurance drove the increase in nonexpansion states. An additional factor the authors examined was type of treatment facility, and this number changed, too. PLWHC usually received treatment at teaching facilities/research programs, and this improved to 46.7% from 40.2%.
Digging deeper, the results are not all positive. In nonexpansion versus expansion states, PLWHC still had higher uninsured rates (16.7% vs 4.2%), were treated more often at comprehensive community cancer programs (26.9% vs 18.6%), and lived in lower median income areas (36.3% vs 26.9%).
Several conclusions can be drawn from this study:
“We didn’t see differences in insurance coverage translate to differences in cancer treatment; however, longer follow-up time is needed to fully evaluate this and the impact of insurance on cancer survival for people with HIV,” stated Gita Suneja, MD, MSHP, who led the team of researchers at the Duke University School of Medicine.
Korrigan KL, Nogueira L, Yabroff KR, et al. The impact of the Patient Protection and Affordable Care Act on insurance coverage and cancer-directed treatment in HIV-infected patients with cancer in the United States [published online November 11, 2019]. Cancer. doi: 10.1002/cncr.32563.