Medicaid enrollment continuity tied to lymphoma stage at diagnosis

Continuous enrollment in Medicaid was associated with a lower rate of a late-stage lymphoma diagnosis in children and adolescents/young adults (AYAs). However, fewer than half of Medicaid-insured patients in these age ranges were continuously enrolled before diagnosis, according to a study published in Blood Advances.

Lymphoma—which is divided into two types, Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL)—is a cancer of the lymphatic system and the third most common cancer among children (ages 0–14 years) and AYAs (ages 15–39 years) in the United States. New treatment options have emerged for the disease, increasing the five-year survival rate, but there is a significant outcomes gap between insured and uninsured children and AYAs with lymphoma.

In an observational study of 3,524 participants with HL or NHL, Xu Ji, Ph.D., assistant professor in the department of pediatrics at Emory University School of Medicine and Aflac Cancer & Blood Disorders Center at Children’s Health care of Atlanta, and her colleagues used the Surveillance, Epidemiology, and End Results (SEER) cancer registry and Medicaid enrollment data to determine if there was an association between the timing of Medicaid enrollment and coverage continuity with lymphoma stage at diagnosis in children and AYAs enrolled in Medicaid.

“Many people do not enroll in Medicaid, despite being eligible, until something happens, such as a cancer diagnosis,” said Dr. Ji. “However, it may be too late at that point because they have lost the opportunity to access preventive or primary care for early evaluation of signs and symptoms and timely referral to oncologists for diagnostic testing and therapy initiation.”

Researchers found that, of 3,524 Medicaid-insured children and AYAs with lymphoma, 37.8% (n = 1,333) were continuously enrolled (12 or more months before diagnosis), 35.2% (n = 1,241) were newly enrolled (month prior to, month of, or less than two months after diagnosis), and 27.0% (n = 950) exhibited other enrollment patterns (enrolled in Medicaid for some time during the 12 months preceding and two months after diagnosis).

Non-Hispanic Black patients, Hispanic patients, children ages 14 and under, and patients from neighborhoods with the lowest socioeconomic status were the most likely to be continuously enrolled in Medicaid.

Among the entire sample, 32.2% of patients presented with stage IV lymphoma, the most advanced stage, at diagnosis. The model-adjusted probability of having stage IV lymphoma at diagnosis was 40% for patients newly enrolled in Medicaid, 31% for those with other enrollment patterns, and 26% for those continuously enrolled.

“These results show that continuous Medicaid coverage was strongly linked to a lower likelihood of a late-stage lymphoma diagnosis,” said Dr. Ji. “However, of Medicaid-insured children and AYAs, only three in eight had continuous coverage. AYAs, who had a stronger link between continuous Medicaid coverage and lower likelihood of a late-stage diagnosis, were less likely to be continuously enrolled in Medicaid.”

A late-stage lymphoma diagnosis is associated with more intensive treatment, disease progression or relapse, and a higher risk of morbidity.

“Catching early onset of symptoms and conducting early evaluation is crucial,” said Dr. Ji. “The earlier we can diagnose lymphoma, the better the prognosis, and the less likely it is that the patient ends up in the emergency department or is hospitalized.”

During the COVID-19 pandemic, states paused eligibility redeterminations for Medicaid; however, this provision ended in 2023, resulting in widespread disenrollment of more than 25.1 million individuals as of August 2024.

“What we’re seeing now in terms of Medicaid disenrollment is really unfortunate because continuous coverage is critical for timely access to care,” said Dr. Ji. She and her colleagues suggested that the provision of 12 or 24 months of uninterrupted Medicaid coverage without the need for eligibility recertification could slow coverage disruptions.

They hope this study prompts greater state or federal efforts to help individuals navigate Medicaid’s approval and recertification processes, ultimately leading to fewer late-stage lymphoma diagnoses.

Given the observational nature of the study, there were a few limitations, including a lack of data on patients’ health care utilization prior to cancer diagnosis, an inability to establish causality, and a lack of information on private or other insurance enrollment before, during, or after diagnosis for patients who did not enroll in Medicaid or experienced Medicaid coverage disruptions.

The researchers are continuing their research to better understand why patients wait until diagnosis to enroll in Medicaid.