Association Between Medicaid Expansion and Diagnosis and Management of Colon Cancer

Abstract

BACKGROUND: The Affordable Care Act facilitated improved insurance coverage for states that expanded Medicaid coverage, but the impact on cancer outcomes is unclear. This study compared changes in the diagnosis and management of colon cancer in states that did and did not participate in Medicaid expansion. STUDY DESIGN: Using a quasi-experimental difference-indifferences (DID) approach, we analyzed Medicaid and uninsured patients in the National Cancer Data Base during 2 time periods: pre (2011-2012) and post expansion (2015-2016). Patients in non-expansion states were compared with those in January 2014 expansion states with regard to changes in patient and facility characteristics, cancer staging, treatment decisions, and surgical outcomes. RESULTS: Along with increased Medicaid coverage (DID ¼ 20.27; p < 0.001), patients in expansion states had an increase in stage I diagnoses (DID ¼ 2.97; p ¼ 0.035), distance traveled (miles, DID ¼ 6.67; p ¼ 0.005), and treatment at integrated network programs (DID ¼ 2.67; p ¼ 0.045). More early-stage patients were treated within 30 days (DID ¼ 7.24; p ¼ 0.035) and more stage IV patients received palliative care (DID ¼ 5.01; p ¼ 0.048). Among surgical patients, Medicaid expansion correlated with fewer urgent cases (< 7 days, DID ¼ e5.88; p ¼ 0.008) and more minimally invasive surgery (DID ¼ 5.00; p ¼ 0.022). There were no observed differences in postoperative outcomes or adjuvant chemotherapy. CONCLUSIONS: Medicaid expansion correlated with earlier diagnosis, enhanced access, and improved surgical care for colon cancer patients. These findings highlight the importance of improving health insurance coverage and can help guide future policy efforts.

Medicaid expansion and the management of pancreatic cancer

“…We have recently reported a similar analysis of colon cancer diagnosis and management using the NCDB. 16 In that study, Medicaid expansion correlated with earlier diagnosis, more travel and less delays for care, less urgent surgery, more minimally invasive surgery, and more palliative care for stage IV patients. These studies highlight the possibilities and limitations of insurance expansion.…”

“…15 This analysis was performed using methods similar to a recent report on colon cancer using the NCDB. 16 We first selected all pa- We narrowed our patient cohort to two time periods: 2011-2012 and 2015-2016. Our goal was to compare the most recent possible cohort to a modern cohort before ACA Medicaid expansion.…”

“…Finally, we limited our analysis to patients age 40-64 who either had Medicaid coverage or were uninsured, excluding the~75% of patients in the NCDB pancreatic cancer cohort with Medicare or private insurance. 16 Some studies have included all insurance types in their analysis. 8,10,13 Medicaid expansion was meant to improve coverage for patients without health insurance and should have little impact on cancer patients who are eligible for Medicare or have access to coverage through their employer 17 ; the patients theoretically most affected by Medicaid expansion are those with Medicaid or no health insurance.…”

“…Therefore, we chose to perform a more targeted analysis of only Medicaid and uninsured patients. 13,16 As Medicaid expansion status is suppressed for age 0-39 in the NCDB, only patients age 40-64 were included in this analysis.…”

“…This methodology has been used widely to study the impact of Medicaid expansion on insurance coverage and other patient characteristics. 8,10,16 For this study, the nonexpansion states served as the "control" group and the January 2014 expansion states served as the "experimental" group. For any given variable, we first identified the change between time periods for the nonexpansion states, described in absolute and relative terms.…”