The effect of Medicaid expansion among adults from low‐income communities on stage at diagnosis in those with screening‐amenable cancers

Abstract

Background Several states have opted to expand Medicaid under the Patient Protection and Affordable Care Act (ACA), which offers insurance coverage to low‐income individuals up to 138% of the federal poverty level. This expansion of Medicaid to a medically vulnerable population potentially can reduce cancer outcome disparities, especially among patients with screening‐amenable cancers. The objective of the current study was to estimate the effect of Medicaid expansion on the percentage of adults from low‐income communities with screening‐amenable cancers who present with metastatic disease. Methods Using state cancer registry data linked with block group–level income data, a total of 12,760 individuals aged 30 to 64 years who were diagnosed with incident invasive breast (female), cervical, colorectal, or lung cancer from 2011 through 2016 and who were uninsured or had Medicaid insurance at the time of diagnosis were identified. This sample was probability weighted based on income to reflect potential Medicaid eligibility under the ACA's Medicaid expansion. A multivariable logistic model then was fitted to examine the independent association between the exposure (pre‐expansion [years 2011‐2013] vs postexpansion [years 2014‐2016]) and the outcome (metastatic vs nonmetastatic disease at the time of diagnosis). Results After adjusting for potential confounders, individuals who were diagnosed postexpansion were found to have 15% lower odds of having metastatic disease compared with those who were diagnosed pre‐expansion (adjusted odds ratio, 0.85; 95% confidence interval, 0.77‐0.93). As a control, a separate analysis that focused on individuals with private insurance who resided in high‐income communities found nonsignificant postexpansion (vs pre‐expansion) changes in the outcome (adjusted odds ratio, 1.02; 95% confidence interval, 0.96‐1.09). Conclusions Medicaid expansion is associated with a narrowing of a critical cancer outcome disparity in adults from low‐income communities.

Determining the impact of Medicaid expansion on cancer burden

“…The findings of the study by Kim et al 8 are consistent with a vast literature attempting to describe the impact of Medicaid expansion on cancer outcomes. For example, Takvorian et al examined the association between Medicaid expansion and stage of disease at the time of diagnosis among patients with breast, colon, and lung cancer, leveraging the National Cancer Data Base, and observed that Medicaid expansion was associated with an increased rate of the diagnosis of early‐stage cancer 9 .…”

“…In addition to Medicaid expansion, the ACA included multiple provisions that sought to enhance screening and early cancer detection, such as requiring Medicare and non‐grandfathered private health insurance policies to provide coverage for grade A or B preventive care services as defined by the United States Preventive Services Task Force (USPSTF) without cost sharing 21 . The impact of these measures cannot be isolated from Medicaid expansion in the study by Kim et al 8 …”

“…Future research will need to specifically explore the timing of USPSTF recommendations aimed at detecting cancer early as they relate to the percentage of incident metastatic cases within the context of Medicaid expansion. However, conclusions from the study by Kim et al 8 study have suggested that, overall, ACA provisions may be effective strategies for reducing the burden of advanced cancer in the United States.…”

“…In their study in this issue of Cancer , Kim et al 8 examined the role of Ohio's Medicaid expansion in cancer outcome disparities for breast, cervical, colorectal, and lung cancers. Specifically, the authors used population‐level cancer outcome data from the Ohio cancer registry and linked the registry data set to block group–level income data from the American Community Survey, which was used to approximate individual‐level income.…”

“…The analysis by Kim et al 8 has several methodological limitations that are worth discussing. Similar to other studies published to date on this topic, 11 Kim et al were unable to completely isolate the effects of Medicaid expansion 8 from the health care marketplace and Medicaid cost sharing. In addition, excluding elderly adults from their analysis was a serious limitation because policy evaluations that impact a population are more informative if performed on a population level.…”