BACKGROUND:Medical debt is recognized as a social determinant of health. This study examines associations of county-level medical debt in collections with diagnosis stage and survival among individuals newly diagnosed with cancer in the United States. PATIENTS AND METHODS:A cohort of individuals aged ≥18 years newly diagnosed with cancer in 2011-2019 was identified from the National Cancer Database and followed through December 31, 2019. The county-level share of adults with medical debt in collections was combined with patient-level data. Hierarchical multivariable logistic and Cox proportional hazard models estimated associations of county-level medical debt with cancer diagnosis stage and overall survival, respectively, for all patients and by cancer type, clinical, and socioeconomic subgroups. RESULTS:A total of 7,558,658 individuals with cancer were identified, with median county-level medical debt of 18%, ranging from 0% to 56%. Patients in the highest medical debt quartile had the highest proportion with stage IV disease and lowest 5-year survival rate. After adjusting for other patient- and county-level characteristics, patients living in counties in the highest quartile of medical debt were more likely to be diagnosed with stage IV disease (odds ratio, 1.079; 95% CI, 1.064-1.094) and had poorer survival (hazard ratio, 1.072; 95% CI, 1.061-1.082) than those living in counties in the lowest quartile of medical debt, with a statistically significant dose-response relationship (P for trend <.001). Patterns were observed across major cancer types and were consistent across socioeconomic and clinical subgroups. CONCLUSIONS:County-level medical debt was associated with advanced-stage diagnosis and worse survival among individuals newly diagnosed with cancer. Future research is warranted to evaluate the recent and ongoing US policy changes on medical debt prevalence and their effects on cancer care and outcomes.

PURPOSE:Cancer survivors endure costly and time-intensive care throughout treatment and survivorship. Paid sick leave provides employment and financial stability while supporting time off for medical needs. We investigated whether paid sick leave is associated with financial hardship and overall and cancer-specific mortality risk in working adult cancer survivors. METHODS:Working adults age 18-64 years with a cancer history were identified from the National Health Interview Survey (NHIS) between 2011 and 2023. Associations of paid sick leave and financial hardship (medical care delays, problems paying medical bills, worry about paying medical bills, and cost-related medication underuse) were examined with 2011-2018 and 2019-2023 data using separate multivariable logistic regressions because of survey redesign in 2019. Linked mortality files from the National Death Index were available for 2011-2018 respondents. The association of paid sick leave and mortality risk was examined with multivariable Cox proportional hazards models. RESULTS:A total of 8,091 and 3,919 working cancer survivors were identified from the 2011-2018 and 2019-2023 NHIS, respectively. Paid sick leave was associated with decreased medical care delays because of cost (2011-2018 odds ratio [OR], 0.74 [95% CI, 0.60 to 0.93]; P = .008; 2019-2023 OR, 0.51 [95% CI, 0.35 to 0.74]; P < .001) but not consistently with other forms of financial hardship. In adjusted analyses, paid sick leave was associated with significant reductions in risk of overall mortality (hazard ratio [HR], 0.74 [95% CI, 0.61 to 0.9]; P = .003) and cancer mortality (HR, 0.74 [95% CI, 0.61 to 0.91]; P = .003). CONCLUSION:In working cancer survivors, paid sick leave is associated with decreased care delays and lower overall and cancer-specific mortality risk, which may be due to maintained employment, household income, and health insurance coverage leading to improvements in treatment access, affordability, and overall survivorship care.

Importance:More than half of Medicare beneficiaries are now enrolled in Medicare Advantage (MA) plans. These plans offer lower premiums and additional benefits compared with Traditional Medicare (TM) but commonly restrict organization and clinician networks, potentially limiting access to specialists, including oncologists. Little is known about the use of oncology networks in MA plans. Objective:To evaluate effective oncology network breadth under MA plans based on realized health care utilization. Design, Setting, and Participants:This cross-sectional study used linked 2016-2019 Surveillance, Epidemiology, and End Results (SEER)-Medicare data to characterize effective oncology networks among beneficiaries diagnosed with 8 common cancers. Network trends were examined separately for regular MA plans and special needs plans (SNPs) within SEER counties, and network breadth was compared by metropolitan status and plan type (health maintenance organization [HMO], local or regional preferred provider organization [PPO], point-of-service [POS] plan, or other). Data were analyzed between March 1, 2025, and April 1, 2026. Main Outcomes and Measures:Effective oncology network breadth was defined at the plan-county-year level as the share of oncology organizations and oncologists accessed by MA beneficiaries relative to oncology organizations and oncologists accessed by TM beneficiaries in the same county-year, measured separately for oncology organizations, medical or surgical oncologists, and radiation oncologists and more than 1 MA-recorded visit to a National Cancer Institute (NCI)-designated comprehensive cancer center. Results:A total of 807 580 MA beneficiaries (mean [SD] age, 70.4 [9.0] years; 420 662 males [52.1%]) were identified, representing 23 255 plan-year observations for regular MA plans and 17 716 for SNPs from 2016 through 2019. Across regular MA plans, beneficiaries accessed a mean (SD) of 12.0% (12.7%) of oncology organizations, 6.8% (9.6%) of medical or surgical oncologists, and 11.6% (13.8%) of radiation oncologists; across SNPs, beneficiaries accessed 12.4% (12.6%) of oncology organizations, 7.2% (8.6%) of medical or surgical oncologists, and 12.7% (15.5%) of radiation oncologists. MA-recorded visits to NCI-designated comprehensive cancer centers were observed in 25.7% (n = 5983 of 23255) of regular MA plans and 20.5% (n = 3624 of 17716) of SNPs. Effective oncology network breadth was narrower for HMOs; nonmetropolitan (vs metropolitan) counties and regional PPOs (vs other plan types) had lower likelihood of MA-recorded visits to NCI-designated comprehensive cancer centers. Conclusions and Relevance:In this cross-sectional study of MA plans in SEER regions from 2016 to 2019, effective oncology organization and oncologist networks were constrained. Restricted access to NCI-designated comprehensive cancer centers might limit access to innovative treatments and cancer outcomes, which warrants future research.

e23164 Background: With the rising comorbidity burden among cancer patients of older age, understanding the prevalence and added costs of chronic conditions within Medicare’s oncology population is required for value-based care management. Methods: We examined episode costs across seven cancer types using deidentified baseline episode files from Medicare’s Enhanced Oncology Model (EOM) (2016-2020). We first analyzed the prevalence of four common chronic conditions: morbid obesity, hypertension, endocrine disorders, and heart disease based on Hierarchical Condition Category for each cancer. Then we calculated trended winsorized standardized mean patient cost per episode for patients with these chronic conditions and compared with those without any of the four comorbidities as a reference group. Results: Hypertension has the highest prevalence of ~60%, followed by endocrine disorders (> 40%), heart disease (> 28%), and morbid obesity (~5%). Across all cancer types, patients with morbid obesity demonstrated the highest cost burden. Specifically the incremental costs ranged from $3,640 for small intestine/colorectal cancer to $8,194 for lymphoma, increasing 10–15% above the reference group. Heart disease is associated with a $4,600 increase in average cost for chronic leukemia, with a smaller increase seen in myeloma, but no meaningful impact in the other cancers. Prostate cancer patients with any of the four conditions had appreciably higher costs than their reference counterparts. Conclusions: Multiple chronic conditions in cancer patients increase the cost and complexity of oncology care. Specifically, addressing morbid obesity through prevention and tailored management may help reduce costs. Weight management and proactive management of comorbidities, along with integrated care models, may be essential to control costs and enhance outcomes in oncology. Prevalence (%) and patient trended winsorized standardized mean cost by cancer type. Referencegroup Hypertension Heart Disease Endocrine disorder Morbid Obesity Breast Cancer $48,355 (27.5) $47,068 (55.0) $49,358 (28.6) $48,142 (45.6) $54,590 (6.1) Chronic Leukemia $57,853 (18.2) $57,846 (62.3) $62,496 (43.1) $58,865 (49.9) $63,963 (5.6) Lung Cancer $64,667 (20.4) $64,932 (64.0) $64,363 (45.0) $65,353 (48.2) $69,926 (3.9) Lymphoma $55,386 (19.6) $55,337 (60.7) $56,929 (40.4) $56,204 (51.6) $63,580 (4.5) Multiple Myeloma $89,861 (19.4) $86,964 (61.9) $88,560 (40.8) $87,147 (49.5) $95,460 (4.9) Prostate Cancer $46,357 (19.5) $49,019 (65.9) $52,084 (42.7) $50,132 (42.4) $52,794 (4.3) Small Intestine / Colorectal Cancer $38,952 (27.6) $38,330 (59.2) $39,060 (33.6) $38,695 (42.0) $42,592 (5.5)

Objective:To examine the associations of racialized economic segregation with unhealthy behaviors and poor mental health. Methods:We conducted an ecological study with census tract-level measures from the 2018-2022 American Community Survey and 2024 CDC PLACES. Exposure was racialized economic segregation, measured by the Index of Concentration at the Extremes (ICE). Outcomes were the prevalence of unhealthy behaviors (smoking, binge drinking, physical inactivity, obesity, and inadequate sleep) and poor mental health among adults aged ≥18 years. Covariates were census tract's socioeconomic status and metropolitan status. Associations were examined with multivariable linear regression models. Results:Among 83,359 census tracts, the average prevalence was 15.1% for smoking, 17.2% for binge drinking, 25.4% for physical inactivity, 34.4% for obesity, 36.6% for inadequate sleep, and 17.1% for poor mental health. After adjustment, all outcomes except binge drinking showed negative dose-response associations with the ICE, i.e., higher privilege level, lower prevalence of unhealthy behaviors. The prevalence of poor mental health increased by 0.61 (0.55-0.66), 0.98 (0.92-1.04),1.48 (1.41-1.55), and 2.38 (2.30-2.45) percentage points in the four less privileged groups, compared to the most privileged group. Conclusion:Racialized economic segregation is significantly associated with the prevalence of smoking, physical inactivity, obesity, inadequate sleep, and poor mental health.

Additional characteristics of cases diagnosed between 2007-2008 and 2014-2015 by state Medicaid expansion status

PURPOSE:To examine whether Medicare Advantage (MA) enrollment is associated with differences in the timeliness of novel hormonal therapy (NHT) initiation, including abiraterone, enzalutamide, apalutamide, and darolutamide, for metastatic hormone-sensitive prostate cancer (mHSPC), compared with Traditional Medicare (TM), and to explore disparities by race, socioeconomic status (SES), and care setting. METHODS:We conducted a retrospective cohort study using the Flatiron Health Research Database, including 3,215 patients age ≥65 years diagnosed with mHSPC between 2018 and 2023. Timely NHT initiation was defined as receipt within 45 days of diagnosis. Multivariable logistic regression models were adjusted for age, race/ethnicity, year of diagnosis, de novo metastatic status, Eastern Cooperative Oncology Group performance status, SES, and practice type, using inverse probability of treatment weighting to balance baseline characteristics between MA and TM groups. RESULTS:Among the 3,215 patients, 2,011 (63%) were enrolled in TM and 1,204 (37%) in MA. Overall, 25% initiated NHT within 45 days of diagnosis. Compared with TM beneficiaries, MA enrollees was associated with lower odds of timely NHT initiation (adjusted odds ratio [aOR], 0.82 [95% CI, 0.70 to 0.95]; P = .01). Differences were more pronounced among racial and ethnic minority patients (aOR, 0.54 [95% CI, 0.37 to 0.77]), individuals from lower-SES areas (aOR, 0.75 [95% CI, 0.58 to 0.98]), and patients receiving care in community settings (aOR, 0.80 [95% CI, 0.67 to 0.95]). CONCLUSION:MA enrollment was associated with lower odds of timely NHT initiation compared with TM. These associations were particularly evident among underserved groups, highlighting the need to evaluate how MA program structures may influence equitable access to evidence-based cancer care.

11050 Background: Palliative care is a specialized medical approach to improve symptoms and quality of life for patients with serious illnesses, including cancer, yet its utilization remains low. While enrollment in Medicare Advantage (MA) has grown and surpassed Traditional Medicare (TM), less is known about differences in palliative care between MA and TM and the extent to which MA plan design, particularly provider networks, contributes to these differences. Methods: Using the 2025 SEER–Medicare linkage, we identified Medicare beneficiaries aged ≥66 years diagnosed with distant-stage breast, colorectal, lung, pancreatic, or prostate cancer between 2016 and 2021. We included patients who survived at least 2 months after diagnosis and had continuous enrollment in TM or MA from 1 year before diagnosis to death/end of follow-up. The primary outcome was the cumulative incidence of palliative care billing within 6 months of diagnosis. To assess the role of provider networks, we first assigned each patient a treating oncologist based on the plurality of visits with cancer diagnosis codes; we then conducted 1:1 matching of patients enrolled in a given MA plan to patients in TM treated by the same oncologists within the same county. Multivariable Cox proportional hazards models estimated differences in palliative care billing between TM and MA overall and by MA plan type, before and after matching, adjusting for sociodemographic and clinical characteristics. Results: Among 135,402 beneficiaries with advanced cancer, 67.7% were enrolled in TM and 32.3% in MA; over half were female, 7.3% Hispanic, and 9.5% non-Hispanic Black. The 6-month cumulative incidence of palliative care billing was 13.3% among MA beneficiaries and 9.3% among TM beneficiaries. In adjusted analyses, MA enrollment was associated with higher palliative care billing (hazard ratio [HR], 1.39; 95% CI, 1.34–1.44). When stratified by plan types, palliative care was particularly higher among patients in health maintenance organization (HMO) plans (HR=1.66, 95%CI=1.60-1.72) but not other plan types. After matching on treating oncologists, 23,033 TM and 23,033 MA patients were included. Matched MA beneficaries were less likely to have HMO plans than those not matched (49.1% vs. 76.7%). Differences in palliative care were attenuated and statistically non-significant, with cumulative incidence of 11.0% and 10.4% among MA and TM, and an adjusted hazard ratio of 1.05 (95%CI=0.99, 1.11). Similar attenuation was observed in HMO plans (1.16, 95%CI=1.08, 1.24). Conclusions: Palliative care billing was significantly higher among MA than TM beneficiaries, but these differences were substantially reduced after accounting for provider networks. These findings suggest that between-provider variation accounts for the majority of the difference in palliative care receipt between TM and MA beneficiaries.

Purpose: To examine the associations between Medicaid expansion and stage at diagnosis, timely initiation and receipt of guideline-concordant treatment, and 5-year overall survival (OS) among people with non-small cell lung cancer (NSCLC). Methods: Individuals newly diagnosed with stage I to IV NSCLC at age 18-64 years between January 1, 2004, and December 31, 2023, in 50 states and Washington, DC, were identified from the National Cancer Database. We examined the association of Medicaid expansion and (1) early-stage diagnosis (I and II); (2) timely initiation of guideline-concordant treatment within 30 days after diagnosis; (3) receipt of all first-course guideline-concordant treatment; and (4) 5-year OS. We applied conventional and updated (Sun and Abraham) difference-in-differences (DID) approaches to examine the changes in study outcomes associated with Medicaid expansion using multivariable linear probability models to estimate stage and treatment and multivariable flexible parametric survival models to investigate survival overall and by key factors. Results: Compared with people in nonexpansion states (n = 164,228), people in expansion states (n = 350,290) were more likely to be female, non-Hispanic White, or living in areas with higher family income or in nonmetropolitan areas. Medicaid expansion was associated with increases in early-stage NSCLC diagnosis (DID: 1.02 percentage points [ppt; 95% CI, 0.52 to 1.52]), timely treatment initiation (2.10 ppt [95% CI, 0.05 to 4.15]), and higher 5-year OS (1.79 ppt [95% CI, 1.32 to 2.26]). In stratified analyses, people living in areas with lower household income were more likely to benefit from Medicaid expansion. Conclusion: Medicaid expansion was associated with improvements in early detection, timeliness of guideline-concordant treatment, and survival for people with NSCLC. Anticipated Medicaid coverage losses may jeopardize these gains.

12032 Background: Palliative care, a specialized approach focused on care for individuals with serious illness including cancer, has been shown to improve end-of-life outcomes, including higher rates of death in preferred settings. However, access to palliative care remains inequitable due to significant geographic disparities in workforce distribution. This study examines the association between county-level palliative care physician density and place of death among US decedents died from cancer. Methods: We conducted a retrospective cohort study using CDC WONDER multiple cause of death data (2021-2023) linked with palliative care physician supply data from the American Medical Association (AMA) Physician Masterfile. The primary exposure was county-level palliative care physician density, categorized as zero, below-median, or above-median (among non-zero counties). The primary outcome was the county-level percentage of cancer deaths (ICD: C00-C97) occurring in non-hospital settings (home, hospice, long-term care, or nursing home). Covariates include county sociodemographic characteristics (race/ethnicity, median income, region, metropolitan status) and hospice facility availability. Multivariable regression models estimated associations between physician density and place of death, adjusting for other covariates. All models incorporated county population weighting and state-level clustering. Results: Most U.S. counties (n = 2056, 66.27%) had no palliative care physicians in 2020. Counties with palliative care physicians showed higher median household incomes, more hospice facilities and metropolitan status, and were concentrated in the Northeast and West (all p < 0.001). The average percentage of non-hospital facility deaths across all counties was 56.6% (SD = 7.1) for all causes, 60.5% (SD = 8.1) for heart disease, and 70.7% (SD = 8.0) for malignant neoplasms. Multivariable regression models revealed a dose-response relationship: counties with non-zero below median and above-median palliative care physician density showed 0.9 percentage points (ppts, p < 0.05) and 1.1 ppts (p < 0.05) higher proportions of cancer death at non-hospital facility-based facilities than counties without palliative care physicians. In addition, Metropolitan and Micropolitan counties had 2.5 ppts (p < 0.001) and 2.1 ppts (p < 0.001) higher proportions of cancer death at non-hospital facility-based facilities than non-metropolitan counties respectively. Conclusions: Higher county-level palliative care physician density is associated with increased non-hospital facility-based deaths for cancer, demonstrating a clear dose-response relationship. These findings suggest that ensuring access to palliative care, through workforce expansion or care delivery model innovation may facilitate end-of-life care planning aligned with patient preferences.

Importance:Non-small cell lung cancer (NSCLC) is the leading cause of cancer death in the US, with substantial socioeconomic, racial, and geographic disparities. Objective:To evaluate the association between Medicaid expansion and place-based disparities in insurance coverage, early-stage diagnosis, and 3-year overall survival among patients diagnosed with NSCLC. Design, Setting, and Participants:This cohort study used difference-in-differences (DD) and difference-in-differences-in-differences (DDD) analyses in the population-based Cancer Incidence in North America of the North American Association of Central Cancer Registries database. For analyses of insurance coverage and early-stage diagnosis, participants included patients aged 18 to 64 years with NSCLC newly diagnosed from January 1, 2009, to December 31, 2013 (defined as the pre-expansion period), and from January 1, 2015, to December 31, 2019 (defined as the postexpansion period), from 26 states and Washington, DC, that expanded Medicaid eligibility by 2014 and 17 nonexpansion states as of 2019. Survival analysis included patients aged 18 to 61 years in January 1, 2009, to December 31, 2012 (defined as the pre-expansion period), and January 1, 2015, to December 31, 2018 (defined as the postexpansion period), from 26 expansion states and 16 nonexpansion states. For both analyses, 2014 was excluded as the washout period. Data were analyzed from August 1, 2023, to April 30, 2026. Exposure:Medicaid expansion. Main Outcomes and Measures:Outcomes included insurance coverage, localized-stage diagnosis, and 3-year overall survival. Linear probability regressions and flexible parametric survival models were fitted, adjusting for age, sex, and county-level metropolitan status and social deprivation. Stratified analyses were conducted within subgroups defined by census tract-level poverty and county-level poverty, metropolitan status, medically underserved areas, racialized economic residential segregation, and social deprivation. Results:Among 303 503 patients (164 901 [54.3%] male; 216 591 [71.4%] aged 55-64 years), health insurance coverage increased by 5.06 percentage points (pp) (95% CI, 4.80-5.32 pp) in expansion states and by 2.87 pp (95% CI, 2.59-3.16 pp) in nonexpansion states, resulting in adjusted DD of 2.22 pp (95% CI, 1.83-2.60 pp). Similarly, Medicaid expansion was associated with significant increases in localized-stage diagnosis (1.76 pp [95% CI, 1.21-2.30 pp]) and 3-year overall survival (1.89 pp [95% CI, 1.04-2.74 pp]). Improvements were greater among patients residing in socioeconomically disadvantaged areas. For example, the 3-year survival difference associated with Medicaid expansion was 4.22 pp (95% CI, 2.39-6.05 pp) in nonmetropolitan counties but 1.21 pp (95% CI, 0.26-2.17 pp) in metropolitan counties (P = .01 from DDD analysis). Conclusions and Relevance:In this nationwide cohort of patients with NSCLC, Medicaid expansion was associated with improved outcomes, especially among patients residing in socioeconomically vulnerable areas. Patterns are consistent with a narrowing of place-based disparities and support potential benefits of Medicaid expansion and possible implications of projected coverage losses.

Tests for parallel trend assumption in difference-in-differences analyses of Medicaid expansion status associated with five-year cause-specific survival

Changes in 5-year overall survival by sociodemographic characteristics and cancer type

Association between Medicaid Expansion status and 5-year cause-specific cancer survival by (A) race and ethnicity (B) county-level poverty, and (C) rurality

PURPOSE:Since 2012, several states have implemented mandatory paid sick leave (PSL) policies. PSL can provide patients time and income continuity to undergo screening and/or timely diagnostic workup for new cancer-related symptoms and complete lengthy and expensive cancer treatment courses. This study aimed to examine the association between mandatory PSL policies and cancer stage at diagnosis and overall survival (OS). METHODS:Adults age 18-64 years diagnosed with cancer were identified from the Surveillance, Epidemiology, and End Results program registries between 2010 and 2019. Difference-in-differences (DID) analyses were used to compare absolute changes in stage I and stage IV diagnoses and 1-year OS before and after policy implementation in states that enacted mandatory PSL relative to states that did not enact such policies. RESULTS:A total of 1,052,307 patients with cancer were included. In adjusted DID analyses, there were a 0.83 (95% CI = -1.49 to -0.16, P = .014) PP decrease in stage IV diagnoses and a 0.63 (95% CI = 0.10 to 1.17, P = .021) PP increase in 1-year OS associated with implementation of mandatory PSL policies. In exploratory analyses, males and individuals with lung cancer experienced the greatest shifts in policy-associated changes in stage at diagnosis and OS. CONCLUSION:PSL policy implementation is associated with decreased late-stage diagnoses and improved OS in patients with cancer. Policies that improve opportunities to receive medical care may facilitate earlier cancer detection and ultimately contribute to better patient outcomes.

Importance:Hospice is central to end-of-life (EOL) care for patients with advanced cancers and is an excluded benefit under Medicare Advantage (MA), with coverage instead provided by traditional Medicare (TM). With growing MA penetration, more beneficiaries also switch between MA and TM for financial protection and physician access considerations, although less is known about how different Medicare programs and plan switching behaviors affect EOL care for patients with advanced cancers. Objective:To evaluate hospice utilization and places of hospice care by Medicare plan switching patterns. Design, Setting, and Participants:This retrospective cohort study used Surveillance, Epidemiology, and End Results (SEER) Medicare data to identify beneficiaries aged ≥66 years diagnosed with distant-stage female breast, colorectal, lung, pancreatic, or prostate cancers from 2010 to 2019 who died by 2020. Beneficiaries were followed for up to 1 year before death. Data were analyzed from August 1, 2024, to December 14, 2025. Exposure:Plan switching patterns classified as continuous MA, continuous TM, MA to TM, TM to MA, and other (ie, multiple switches). Main Outcomes and Measures:Main outcomes were hospice enrollment in the last year of life and within 3 days of death, total hospice length of stay, and place of last hospice stay (home, nursing home, hospice facility, inpatient facility, or other) using multivariable regressions. Results:The sample included 196 536 decedents (46.5% female, 49.2% aged 66-74 years). Plan switching was infrequent (1.5% TM to MA; 1.8% MA to TM). Those who switched plans were more likely to be members of racial and ethnic minority groups and dual Medicare-Medicaid enrollees. Hospice enrollment was highest for those with continuous MA (74.8%), followed by those who switched from TM to MA (69.0%), those with continuous TM (68.5%), and those who switched from MA to TM (66.4%). Continuous MA beneficiaries had longer hospice stays than continuous TM beneficiaries (48.3 vs 43.8 days). Compared with continuous TM, continuous MA beneficiaries were more likely to receive hospice at home (1.93 percentage points [pp]; 95% CI, 1.40-2.45 pp; P < .001), while those who switched from MA to TM were more likely to receive hospice in nursing homes (2.45 pp; 95% CI, 1.26-3.63 pp; P < .001), particularly among dual Medicare-Medicaid enrollees (6.01 pp; 95% CI, 2.80 to 9.21 pp; P < .001). Conclusions and Relevance:In this cohort study of Medicare decedents with advanced cancers, continuous MA enrollees were most likely to receive hospice at home, while those who switched from MA to TM more frequently received hospice care in nursing homes. Plan switching near the EOL may reflect access barriers, highlighting the importance of addressing care coordination to improve EOL care.

11064 Background: Local and state paid sick leave (PSL) mandates have been associated with increased use of preventive services, including cancer screening, and reduced emergency care utilization. Little research has examined PSL policies and cancer after diagnosis. This study evaluates associations of PSL policies and timely treatment initiation among women with early-stage breast cancer. Methods: We identified patients aged 18-64 years newly diagnosed with stages 0-II breast cancer from the National Cancer Database in 2004-2023 and linked then to area-level policy implementation, measured as the month and year the state, county, or city required PSL. Primary outcomes were receipt of definitive surgery or neoadjuvant therapy within 30, 60, and 90 days of diagnosis. We compared changes in treatment initiation between patients residing in areas with and without PSL policies during and after the month and year of diagnosis. We used a staggered difference-in-differences design to account for differential timing of implementation, adjusting for patient demographics, clinical, and area-level characteristics. Random errors were clustered at the state level. Supplemental analyses stratified by county-level unemployment rates and individual insurance coverage. Results: The study included 1,891,411 patients, of whom 249,313 (13.2%) resided in an area with PSL policies at diagnosis. Patients in areas with PSL policies were more likely to have Medicaid, reside in higher-income and metropolitan areas. PSL policy implementation was significantly associated with a 3.4 percentage point (PPT) increase in the probability of treatment ≤30 days (95% CI: 1.1-5.7), 3.0 PPT increase ≤60 days (95% CI: 1.6-4.3), 1.3 PPT increase ≤90 days (95% CI: 0.5-2.1) (Table). Improvements in timely treatment were concentrated in low-unemployment areas; no significant improvements were observed in high-unemployment areas. The magnitude of associations between PSL policies and treatment initiation was stronger among patients without private insurance than with private insurance. Conclusions: Local and state PSL mandates were associated with earlier treatment initiation among working-age patients with early-stage breast cancer, especially in areas with low female unemployment rate. Findings suggest that PSL policies play an important role in timely cancer treatment for employed women who may not have PSL through their jobs. Association of paid sick leave policies and breast cancer treatment initiation. Time from diagnosis to surgery/neoadjuvant therapy (days) DID PPT Lower 95% CI Upper 95% CI P-value Overall ≤30 3.4 1.1 5.7 0.004 ≤60 3.0 1.6 4.3 0.000 ≤90 1.3 0.5 2.1 0.001 Low female unemployment ≤30 2.2 -0.7 5.0 0.136 ≤60 3.8 1.8 5.8 0.000 ≤90 1.2 0.3 2.2 0.012 High female unemployment ≤30 1.8 -0.6 4.2 0.145 ≤60 -1.2 -4.5 2.0 0.459 ≤90 -1.4 -3.7 0.9 0.232

BACKGROUND:Zero-premium Medicare Advantage (MA) plans have rapidly become the most popular MA plan type in the United States, despite potentially restrictive benefit design. It remains unclear whether the growth of these plans aligns with the county-level cancer mortality. METHODS:We conducted a 2-part, county-level ecological study. First, using Centers for Medicare & Medicaid Services (CMS) enrollment data (2019-2024) and National Center for Health Statistics (NCHS) mortality data (2018-2022), we examined longitudinal trends in the market share of zero-premium MA plans overall and across counties by their cancer-mortality rate quartiles. Second, we performed a cross-sectional, mixed-effects logistic regression analysis of 2019-2024 plan-level data to evaluate the association between zero-premium MA and low plan quality (<4 stars) and whether this relationship varied by county cancer-mortality rate quartile. RESULTS:The market share of zero-premium MA plans increased from 60.2% to 75.9% of the MA market between 2019 and 2024, with disproportionately greater growth in counties with higher cancer mortality rates (Q4: +28.7 percentage points [pp] vs Q1: +23.8 pp; Pinteraction <.001). In adjusted analyses, zero-premium plans also had significantly higher odds of having <4 star ratings compared with premium-charging plans (aOR = 1.68; 95% CI = 1.64 to 1.72), particularly in counties with the highest cancer mortality rates (aOR = 1.83; 95% CI = 1.69 to 1.98, Pinteraction < .01). CONCLUSIONS:The rapid expansion of zero-premium MA plans has been disproportionately concentrated in communities with the highest cancer mortality rates. These plans are more likely to have lower CMS star ratings than premium-charging MA plans. Rapid zero-premium MA plan adoption raises concerns about equitable access to high-quality care for patients with cancer.