Bhambhvani HP, Hampshire K and Eisenberg ML: The association of Medicaid insurance and Affordable Care Act expansions with survival among patients with testicular cancer. Urol Pract 2021; 8: 400.

Starting in 2014, the Affordable Care Act (ACA) offered individual states the opportunity to expand Medicaid coverage to most adults with incomes up to 138% of the federal poverty level—$17,744 for an individual in 2021. In April 2021, Arkansas became the most recent and 39th state to adopt Medicaid expansion, up from the original 25 states, including the District of Columbia, that expanded Medicaid on January 1, 2014. Expansion of Medicaid has been associated with increased access to care for chronic medical conditions such as hypertension and diabetes, as well as improvements in cardiovascular mortality and mortality among end-stage renal disease patients initiating dialysis.^1-3 As most of the states in the country have now made the decision to expand Medicaid, it is important to understand if acquisition of Medicaid insurance is associated with survival among patients with genitourinary malignancies.

Figure. Cumulative incidence plots of mortality in propensity score matched cohorts for seminoma (A) and nonseminoma (B).

In particular, testicular cancer is the most common solid tumor malignancy among men aged 15–34 years.⁴ Young men in this age demographic represent a group that was substantially affected by Medicaid expansions, given historically lower insurance rates than older men, with evidence suggesting proportionately larger gains in insurance coverage than other demographic groups.^5,6 However, recent studies have suggested Medicaid patients with cancer may have limited access to specialized outpatient care, possibly due to lower reimbursement, and that outcomes are similar to patients without insurance.^7,8 As yet, it is unknown if Medicaid insurance is associated with improved survival compared to lack of insurance among patients with testicular cancer.

In our recent study, we leveraged data from the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) database to address this question.⁹ Using both multivariable Cox proportional hazards regression models and multivariable competing risk-adjusted regression, we found no difference in all-cause mortality or cancer-specific mortality between patients with testicular germ cell tumor with Medicaid and those without insurance. To further balance differences in baseline characteristics between patients with Medicaid and those without insurance, we employed 1:1 propensity score matching and found no difference in the cumulative incidence of death due to cancer or death due to noncancer causes (see figure). Patients with private insurance had superior all-cause mortality and cancer-specific mortality rates compared to those without insurance. We confirmed increased enrollment in Medicaid among testicular cancer patients residing in expansion states in 2014. Lastly, no difference in mortality between expansion states and nonexpansion states was observed. Taken together, our results imply that, although Medicaid coverage has increased among testicular cancer patients, acquisition of Medicaid has not improved clinical outcomes.

The prognosis of testicular cancer is generally favorable, and cure rates for stage I disease even approach 100%. As such, it is particularly important to ensure patients have the appropriate access to care and adequate insurance for care. Although the evidence concerning the quality of Medicaid insurance in cancer care is somewhat mixed, recent studies suggest expansion of Medicaid may contribute to improved outcomes for cancers amenable to screening. Indeed, Lam et al found evidence of decreased mortality among patients living in a Medicaid expansion state with newly diagnosed breast, colorectal and lung cancer in the postexpansion period as compared to those living in a nonexpansion state.¹⁰ Our results contribute to a growing body of evidence suggesting Medicaid insurance is suboptimal and similar to lack of insurance among patients with cancers not amenable to screening or with high survival rates, such as testicular cancer. For these patients, policy-level interventions are warranted to improve access to care, utilization of services and ultimately oncologic outcomes.