Disparities in access to cancer surgery after Medicaid expansion

Mesquita-Neto, Jose Wilson; Cmorej, Peter; Mouzaihem, Hassan; Weaver, Donald L.; Kim, Steve; Macedo, Francis I.

doi:10.1016/j.amjsurg.2019.06.023

Cited by 35 publications

(19 citation statements)

References 7 publications

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“…However, our findings also indicate neither policy change was associated with earlier staging at diagnosis. This is in contrast to prior studies indicating reductions in uninsured rates and late stage disease for all young patients with cancer following the ACA-DCE [ 16 , 21 , 22 ]. These inconsistencies may be in part due to relatively short term follow up data following each policy change.…”

Section: Discussioncontrasting

confidence: 99%

Insurance coverage, stage at diagnosis, and time to treatment following dependent coverage and Medicaid expansion for men with testicular cancer

et al. 2020

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Introduction We sought to assess the impact of Affordable Care Act Dependent Care Expansion (ACA-DCE), which allowed dependent coverage for adults aged 19–25, and Medicaid expansion on outcomes for men with testicular cancer. Methods Using a US-based cancer registry, we performed adjusted difference-in-difference (DID) analyses comparing outcomes between men aged 19–25 (n = 8,026) and 26–64 (n = 33,303) pre- (2007–2009) and post-ACA-DCE (2011–2016) and between men in states that expanded Medicaid (n = 2,296) to men in those that did not (n = 2,265)pre- (2011–2013) and post-Medicaid expansion (2015–2016). Results In ACA-DCE analysis, rates of uninsurance decreased (DID -5.64, 95% confidence interval [CI] -7.23 to -4.04%, p<0.001) among patients aged 19–25 relative to older patients aged 26–64. There was no significant DID in advanced stage at diagnosis (stage≥II; p = 0.6) or orchiectomy more than 14 days after diagnosis (p = 0.6). For patients who received chemotherapy or radiotherapy as their first course of treatment, treatment greater than 60 days after diagnosis decreased (DID -4.84%, 95% CI -8.22 to -1.45%, p = 0.005) among patients aged 19–25 relative to patients aged 26–64. In Medicaid expansion states, rates of uninsurance decreased (DID -4.20%, 95% CI -7.67 to -0.73%, p = 0.018) while patients receiving chemotherapy or radiotherapy greater than 60 days after diagnosis decreased (DID -8.76, 95% CI -17.13 to -0.38%, p = 0.040) compared to rates in non-expansion states. No significant DIDs were seen for stage (p = 0.8) or time to orchiectomy (p = 0.1). Conclusions Men with testicular cancer had lower uninsurance rates and decreased time to delivery of chemotherapy or radiotherapy following ACA-DCE and Medicaid expansions. Time to orchiectomy and stage at diagnosis did not change following either insurance expansion.

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Section: Discussioncontrasting

confidence: 99%

Insurance coverage, stage at diagnosis, and time to treatment following dependent coverage and Medicaid expansion for men with testicular cancer

et al. 2020

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“…For the uninsured in particular, this highlights a population that would benefit from greater access to screening and treatment options through Medicaid expansion and increased funding of screening programs. With the passing of the ACA, there has been a decrease in the rate of uninsured patients 32,33 as well as fewer patients with advanced cancer stages at diagnosis 34,35 in the states that have expanded Medicaid. This study adds to the ongoing body of research and the public health push for Missouri and other states to consider Medicaid expansion as a protection for their most vulnerable populations 36,37 .…”

Section: Discussionmentioning

confidence: 99%

Relationship between insurance status and outcomes for patients with breast cancer in Missouri

Berrian

Liu

Lian

et al. 2020

Cancer

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Background The cancer stage at diagnosis, treatment delays, and breast cancer mortality vary with insurance status. Methods Using the Missouri Cancer Registry, this analysis included 31,485 women diagnosed with invasive breast cancer from January 1, 2007, to December 31, 2015. Odds ratios (ORs) of a late‐stage (stage III or IV) diagnosis and a treatment delay (>60 days after the diagnosis) were calculated with logistic regression. The hazard ratio (HR) of breast cancer mortality was calculated with Cox proportional hazards regression. Mediation analysis was used to quantify the individual contributions of each covariate to mortality. Results The OR of a late‐stage diagnosis was higher for patients with Medicaid (OR, 1.72; 95% confidence interval [CI], 1.56‐1.91) or no insurance (OR, 2.30; 95% CI, 1.91‐2.78) in comparison with privately insured patients. Medicare (OR, 1.21; 95% CI, 1.10‐1.37), Medicaid (OR, 1.60; 95% CI, 1.37‐1.85), and uninsured patients (OR, 1.58; 95% CI, 1.18‐2.12) had higher odds of a treatment delay. The HR of breast cancer–specific mortality was significantly increased in the groups with public insurance or no insurance and decreased after sequential adjustments for sociodemographic factors (HR, 2.39; 95% CI, 1.96‐2.91), tumor characteristics (HR, 1.28; 95% CI, 1.05‐1.56), and treatment (HR, 1.23; 95% CI, 1.01‐1.50). Late‐stage diagnoses accounted for 72.5% of breast cancer mortality in the uninsured. Conclusions Compared with the privately insured, women with public or no insurance had a higher risk for advanced breast cancer, a >60‐day treatment delay, and death from breast cancer. Particularly for the uninsured, Medicaid expansion and increased funding for education and screening programs could decrease breast cancer disparities.

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“…Particularly in the United States, where universal care is not available and there are tiered insurance systems, access to care is particularly relevant as it pertains to insurance status. A number of studies have examined the Affordable Care Act (ACA) and its role in expanding care 25‐28 . These studies have shown that the ACA led to a significant decrease in the number of uninsured patients with HNSCC and a subsequent increase in the number of patients enrolled in Medicaid and private insurance 25,29 .…”

Section: Discussionmentioning

confidence: 99%

“…A number of studies have examined the Affordable Care Act (ACA) and its role in expanding care. [25][26][27][28] These studies have shown that the ACA led to a significant decrease in the number of uninsured patients with HNSCC and a subsequent increase in the number of patients enrolled in Medicaid and private insurance. 25,29 The population level changes in insurance statuses for HNSCC in these studies show that policy changes can have impactful implications for patients.…”

Section: Discussionmentioning

confidence: 99%

Role of physician density in predicting stage and survival for head and neck squamous cell carcinoma

et al. 2020

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Background: Identifying and linking barriers to access to head and neck cancer care, specifically provider density, to stage of diagnosis and survival outcomes is important to serve as a foundation for policy interventions. Methods: Retrospective cohort study using patients with head and neck squamous cell (HNSCC) in the Surveillance, Epidemiology, and End Results (SEER) database from 2007 to 2016 and Area Resource File. Primary outcomes included stage of presentation and cancer-specific 5-year survival and relation to provider density. Results: The initial cohort consisted of 18 342 patients with oral cavity, 21 809 oropharyngeal, 15 860 laryngeal, and 2887 patients with hypopharyngeal malignancy. Non-Hispanic Black race and being uninsured increased the odds of presenting with advanced stage HNSCC and increased hazard of death. There was no significant and consistent association identified between Health Service Areas provider density and advanced stage at diagnosis or cancerspecific 5-year mortality. Conclusions: Provider density of otolaryngologists and primary care physicians and dentists was not significantly associated with stage of presentation or cancer-specific survival for HNSCC while race and insurance status remained independent predictors for worse outcomes. K E Y W O R D S cancer, geographic variation, head and neck squamous cell carcinoma, physician density, provider density, survival 1 | INTRODUCTION Disparities in cancer outcomes arising from lack of access to safe, timely, and affordable care are associated with delays in care, increased morbidity, and higher mortality rates. 1-4 Geographical access and the ability to navigate the complex healthcare system may additionally affect access to care for patients with cancer. People of lower socioeconomic status suffer from disparities in access to high-quality care from a constellation of intricately linked factors, with known independently associated Shekhar K. Gadkaree and Justin C. McCarty denote equal contributions as first author of manuscript.

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Disparities in access to cancer surgery after Medicaid expansion

Cited by 35 publications

References 7 publications

Insurance coverage, stage at diagnosis, and time to treatment following dependent coverage and Medicaid expansion for men with testicular cancer

Insurance coverage, stage at diagnosis, and time to treatment following dependent coverage and Medicaid expansion for men with testicular cancer

Relationship between insurance status and outcomes for patients with breast cancer in Missouri

Role of physician density in predicting stage and survival for head and neck squamous cell carcinoma

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