Association of Medicaid expansion and insurance status, cancer stage, treatment and mortality among patients with cervical cancer

Abstract

Background: Currently, little is known about the effect of the Patient Protection and Affordable Care Act's Medicaid expansion on care delivery and outcomes in cervical cancer.Aim: We evaluated whether Medicaid expansion was associated with changes in insurance status, stage at diagnosis, timely treatment, and survival outcomes in cervical cancer.Methods and results: Using the National Cancer Database, we performed a difference-in-differences (DID) cross-sectional analysis to compare insurance status, stage at diagnosis, timely treatment, and survival outcomes among cervical cancer patients residing in Medicaid expansion and nonexpansion states before (2011)(2012)(2013) and after (2014-2015) Medicaid expansion. January 1, 2014 was used as the timepoint for Medicaid expansion. The primary outcomes of interest were insurance status, stage at diagnosis, treatment within 30 and 90 days of diagnosis, and overall survival. Fifteen thousand two hundred sixty-five patients (median age 50) were included: 42% from Medicaid expansion and 58% from nonexpansion states. Medicaid expansion was significantly associated with increased Medicaid coverage (adjusted DID = 11.0%, 95%CI = 8.2, 13.8, p < .01) and decreased rates of uninsured (adjusted DID = −3.0%, 95%CI = −5.2, −0.8, p < .01) among patients in expansion states compared with non-expansion states. However, Medicaid expansion was not associated with any significant changes in cancer stage at diagnosis or timely treatment. There was no significant change in survival from the pre-to post-expansion period in either expansion or nonexpansion states, and no significant differences between the two (DID-HR = 0.95, 95%CI = 0.83, 1.09, p = .48). Conclusion:Although Medicaid expansion was associated with an increase in Medicaid coverage and decrease in uninsured among patients with cervical cancer, the effects of increased coverage on diagnosis and treatment outcomes may have yet to unfold. Future studies, including longer follow-up are necessary to understand the effects of Medicaid expansion.

In pursuit of equity in cancer care: Moving beyond the Affordable Care Act

“…As Snyder and colleagues suggest, these findings lend support for the role Medicaid expansion has in improving cancer diagnosis, care, and outcomes, corroborating prior studies 8, 13, 34 . Work using data from patients who receive treatment at community health centers (CHCs), which provide primary care for people who are underserved regardless of insurance status, 35 lends insight into how decreasing barriers to care for people who lack insurance can improve access to cancer screening.…”

“…As Snyder and colleagues suggest, these findings lend support for the role Medicaid expansion has in improving cancer diagnosis, care, and outcomes, corroborating prior studies. 8,13,34 Work using data from patients who receive treatment at community health centers (CHCs), which provide primary care for people who are underserved regardless of insurance status, 35 lends insight into how decreasing barriers to care for people who lack insurance can improve access to cancer screening. One study found that in the CHC setting wherein health insurance is not a barrier to care, rates of colorectal and cervical cancer screening increased after implementation of the ACA; the same study found that in the CHC setting, rates of cervical cancer screening increased the most among Black patients in MES.…”

Association of Medicaid expansion with racial disparities in cancer stage at presentation

“…Several studies have similarly utilized the NCDB to measure changes in insurance and stage at presentation following Medicaid expansion, most finding measurable increases in insurance coverage and modest effects cancer stage, concordant with the findings of this study and suggestive of the need for longer follow-up to identify measurable change. [6][7][8][9] One early study examined changes in stage at diagnosis over time for 17 common cancer types based on Medicaid expansion status and identified subtle shifts towards presentation with stage I disease in colorectal, lung, and breast cancer in expansion vs. nonexpansion states from 2011-2014. However, these were not significant on adjusted DID analysis.…”

“…Although six states expanded in 2010, most participating states initiated Medicaid expansion in January 2014. A number of studies have demonstrated improved rates of colorectal, breast, cervical, and prostate cancer screening among patients residing in expansion states, suggesting evidence of the intended benefit of Medicaid expansion 1‐6 . Several early studies have also reported an increased percentage of early stage disease among patients residing in Medicaid expansion states and diagnosed with breast, colorectal (CRC), head and neck, and lung cancer 7‐9 …”

“…A number of studies have demonstrated improved rates of colorectal, breast, cervical, and prostate cancer screening among patients residing in expansion states, suggesting evidence of the intended benefit of Medicaid expansion. [1][2][3][4][5][6] Several early studies have also reported an increased percentage of early stage disease among patients residing in Medicaid expansion states and diagnosed with breast, colorectal (CRC), head and neck, and lung cancer. [7][8][9] Despite recent improvements in cancer screening and treatment, marked racial disparities exist among patients with cancer, including three of the most common malignancies: colorectal, lung, and breast cancer.…”