Changes in Medicaid Enrollment Among Adult Survivors of Childhood Cancer After Medicaid Expansion: A Report From the Childhood Cancer Survivor Study

PURPOSE Little is known about whether Medicaid expansion under the Affordable Care Act affects insurance coverage among adult survivors of childhood cancer, a high-risk population requiring lifetime follow-up care. We examined the association of Medicaid expansion with Medicaid enrollment among participants in the Childhood Cancer Survivor Study. METHODS We identified 13,355 adult survivors (age 18-64 years) diagnosed with cancer at age <21 years between 1970 and 1999 and linked these survivors to Medicaid administrative data from 2010 to 2019. Outcomes included the percentage of survivors with any Medicaid enrollment and Medicaid-covered days (total number of days when a survivor was enrolled in Medicaid) each year. Multivariable difference-in-differences (DD) models were used to examine outcome changes (post- v pre-expansion) in expansion versus nonexpansion states. RESULTS Medicaid enrollment rates among survivors increased in expansion states (17.1% pre-expansion to 22.8% postexpansion) but decreased in nonexpansion states (16.6%-15.7%), leading to a net increase of 7.1 percentage points (ppts; 95% CI, 6.1 to 8.1). The DD model also showed a net mean increase of 18.7 days/year (95% CI, 15.0 to 22.4) in Medicaid-covered days in expansion relative to nonexpansion states. The expansion-associated increase in enrollment was greatest among survivors who were age 18-29 years (11.2 ppts; 95% CI, 8.3 to 14.1), non-Hispanic Black (13.6 ppts, 95% CI, 8.8 to 18.4) or Hispanic (13.4 ppts, 95% CI, 7.0 to 19.8), with <$20K in US dollars (USD) self-reported household income (13.5 ppts, 95% CI, 10.7 to 16.3), and noncollege graduates (9.3 ppts, 95% CI, 7.7 to 10.9). Similar patterns were observed when examining Medicaid-covered days. CONCLUSION To our knowledge, we provide the first evidence of increased Medicaid enrollment and longer coverage duration among adult survivors of childhood cancer after Medicaid expansion. Greater increases were seen among survivors from underrepresented racial/ethnic backgrounds, young adult survivors, and those with lower socioeconomic status, providing a mechanism to reduce disparities and ensure long-term medical care for childhood cancer survivors.

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