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Medicaid Expansion is Associated with Increased Utilization in Palliative Treatments for Metastatic Prostate, Lung, Colon and Breast Cancer in the United States
Stephen Reese, MD¹, Alexander P. Cole, MD¹, Marco Paciotti, MD², Brandon A. Mahal, MD³, Nelya Melnitchouk, MD⁴, Zara Cooper, MD⁴, Adam S. Kibel, MD⁵, Quoc-Dien Trinh, MD¹.
¹Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School,, Boston, MA, ²Department of Urology, Humanitas Clinical and Research Center IRCCS, Rozzano, Italy, ³Department of Radiation Oncology, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, Boston, MA, ⁴Division of Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School,, Boston, MA, ⁵Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School,, Boston, MA.

Background: Policies to increase insurance coverage may influence receipt of palliative treatments for men and women with cancer. The 2010 Affordable Care Act restructured Medicaid eligibility and allowed for states to expand Medicaid coverage to those earning up to 138% of the federal poverty level, however not all states opted to expand Medicaid. We assessed whether state-level expansion of Medicaid insurance coverage following the 2010 Affordable Care Act was associated with increase in palliative treatments
Methods: In this registry-based study, men and women aged 40-65, diagnosed with metastatic prostate, lung, colon and breast cancer from 2010-2016 were identified. The Medicaid expansion status of the state where each patient was diagnosed was the main exposure of this study. A multilevel mixed effect logistic regression model with a facility level random intercept to account for unmeasured hospital characteristics was used to assess for independent predictors of receiving palliative treatments. To assess whether trends differed based on Medicaid
expansion status, an interaction term was fit combining both year and Medicaid expansion status of the state of diagnosis. The multilevel model was used to estimate probabilities of receiving palliative care for each year, for men and women in expansion and non-expansion states.
Results: The probability of receiving palliative treatments has increased from 2010 to 2016 in both expansion and non-expansion states. Patients treated in non-expansion states initially had a higher probability of receiving palliative treatments, however the rate of increase was greater in Medicaid expansion states (p_interaction = 0.001) and by the end of the study the probability of receiving palliative treatments was greater in expansion states than in non-expansion states. The use of palliative treatments for patients with metastatic cancer, has increased from 2010 to 2016 with a greater increase in states which implemented Medicaid expansion.
Conclusions: Expansion in insurance coverage is associated with an increase in utilization of palliative care treatment.

Table 1: Predictors of Palliative Treatments for Men with Metastatic Prostate, Lung, Colon and Breast Cancer on Multivariable Analysis with a Facility Level Random Intercept (N= 212,663)
	Odds Ratio (95% CI)	P value
Year of Diagnosis
(per year)	1.06 (95% CI 1.05-1.06)	<0.001
Age Group
36-40	Ref
41-45	1.09 (0.94 –1.25)	0.25
46-50	1.11 (0.96 –1.27)	0.16
51-55	1.11 (0.97-1.27)	0.14
56-60	1.10 (0.93 – 1.26)	0.18
60-65	1.06 (0.93 – 1.22)	0.36
Race
White	Ref
Black Non-Hispanic	1.04 (1.00 – 1.07)	0.03
Hispanic	0.99 (0.94 – 1.06)	0.83
Asian	1.02 (0.95-1.09)	0.61
Other	1.07 (0.95 –1.20)	0.29
Unknown	0.78 (0.68 –0.90)	0.001
Charlson Comorbidity Index
0	Ref
1	1.03 (1.00 –1.06)	0.06
2	1.04 (1.00 –1.10)	0.05
≥3	1.04 (0.96 – 1.11)	0.23
Mean Family Income in County of Residence
>$63,000	Ref
$49,000-62,999	1.03 (1.00 –1.07)	0.06
$38,000-47,999	0.99 (0.95 –1.02)	0.53
<$38,000	1.03 (0.99–1.07)	0.12
Unknown	0.94 (0.77–1.16)	0.58
Medicaid Expansion Status
Expansion	Ref
Non-expansion	1.26 (1.10 –1.44)	0.001
Medicaid Non-Expansion*Year
	0.98 (0.97 – 0.99)**	Pinteraction = 0.001
* Estimated from American County Survey, regarding patients' county of residence. ** Odds ratio corresponds to the difference in difference of odds ratio as you increase by one year in the non-expansion group versus increasing by one year in the expansion group.

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