Impact of Medicaid Expansion on Rhinologic Cancer Presentation, Treatment, and Outcomes

Abstract

Objective: The United States Patient Protection and Affordable Care Act allocated funds for states to expand Medicaid coverage. However, several states declined expansion. We aim to determine whether Medicaid expansion is associated with healthcare coverage, cancer stage at diagnosis, treatment, and survival among patients with rhinologic cancer. Rhinologic cancer was defined to include cancer of the nasal cavity, paranasal sinus, nasopharynx, or olfactory nerve.Study design: Cohort study. Methods: Patients diagnosed with primary rhinologic malignancies between 2007 to 2016 were extracted from the National Cancer Institute Surveillance, Epidemiology, End Results (SEER) registry. Patients were grouped by diagnosis before and after 2014 (when Medicaid expansion became effective) and whether their state had expanded Medicaid. Multivariable logistic regression controlling for age, sex, race, ethnicity, and income/education was utilized to examine associations between Medicaid expansion/insurance status and stage at diagnosis, treatment, and survival. Overall and disease-specific survival were examined using Kaplan-Meier analysis.Results: Analysis included 10,164 patients. The proportion of uninsured patients decreased after 2014 (2.4%) compared to before 2014 (4.8%, P < .001). After 2014, patients in nonexpanded states were more likely to be diagnosed with advanced stage disease compared to patients in expanded states (N = 2,364; OR = 1.27, 95% CI 1.01-1.60). Being uninsured in any state was associated with advanced stage disease at diagnosis (OR = 1.75, 95% CI 1.41-2.22) and increased risk of disease-specific death (HR = 1.54, 95% CI 1.32-1.82). Survival measures were not associated with diagnosis before versus after 2014 or Medicaid expansion.Conclusions: Patients lacking insurance or residing in nonexpanded states may be more likely to present with advanced stage rhinologic cancer. Longitudinal studies should validate these findings.

Inequities Associated With Advanced Stage at Presentation of Head and Neck Cancer

“…A total of 2830 studies were initially identified for screening, of which 50 were included in the review . Reasons for exclusion are depicted in the Figure.…”

“…The most studied HNC subsite was laryngeal cancer with 25 studies (50%), followed by oral cavity and oropharynx, each with 19 studies (38%). The most assessed outcome was advanced overall stage at presentation or diagnosis among 37 studies (74%) . Other options included advanced tumor size, advanced nodal disease, metastatic disease at presentation, and delayed diagnosis.…”