To determine whether insurance expansions implemented through the Patient Protection and Affordable Care Act (ACA) were associated with changes in insurance coverage status, stage at diagnosis, and overall survival for patients with Renal Cell Carcinoma (RCC).

We identified patients 40 to 64 years old with RCC between 2010 and 2016 in the National Cancer Database. States were categorized as participating on-time in Medicaid expansion or not participating, late and early Medicaid expansion states were excluded.  Patients were stratified into localized (Stage 1/2) and advanced (Stage 3/4) RCC groups and into low- [(≤153% Federal Poverty Guidelines (FPG)], middle- (>153% to 241% FPG) and high-income (≥241% FPG) groups.  Stage trend analysis was performed to assess for stage migration based on income status amongst patients in expansion and non-expansion states.  We performed Difference-in-Difference (DID) modeling to compare reductions in being uninsured and being diagnosed with advanced disease between expansion and non-expansion states.  Cox Regression Multivariable Analysis was conducted to assess all-cause mortality (ACM) for patients before and after ACA implementation for the entire cohort and the intention to treat cohort.

We analyzed 78,099 patients who met inclusion criteria. Following ACA implementation, Absolute Percentage Change (APC) of patients with insurance increased in both expansion and non-expansion states by 4.0% and 2.1%, respectively. In our adjusted DID analysis, the rate of being uninsured declined in expansion states by -1.14% (p<0.001) compared to non-expansion states.  Largest increases occurred in expansion states, with increased acquisition of Medicaid by low-income (APC +11.0% p<0.001), middle-income (APC +4.20% p<0.001), and high-income (+4.00%, p<0.001). Stage trend analysis revealed a higher proportion of patients with localized RCC after ACA implementation in low-income (APC +4.0% p<0.001) and middle-income (APC +1.6% p=0.023.) patients in expansion.  Cox Regression for the entire cohort and in the intention to treat cohort revealed that before ACA implementation, low-income was associated with a higher risk of mortality, and was attenuated following ACA.

Following the implementation of the Affordable Care Act the proportion of patients with newly diagnosed RCC with health insurance increased with the largest effects seen in Medicaid expansions states. In addition, higher proportions of patients were diagnosed with localized disease in Medicaid expansion states amongst low- and middle-income patients and in non-Medicaid expansion states amongst middle income patients. Furthermore, low income status ceased being a risk factor for mortality following ACA implementation. Our findings suggest that ACA implementation has been associated with downward stage migration in low/middle-income patients and attenuation of income status as a risk for mortality in RCC. Further investigation is requisite.