Abstract
The effect of the Patient Protection and Affordable Care Act's Medicaid expansion on cancer care delivery and outcomes is unknown. Patients with cancer are a high-risk group for whom treatment delays are particularly detrimental. To examine the association between Medicaid expansion and changes in insurance status, stage at diagnosis, and timely treatment among patients with incident breast, colon, and non-small cell lung cancer. This quasi-experimental, difference-in-differences (DID) cross-sectional study included nonelderly adults (aged 40-64 years) with a new diagnosis of invasive breast, colon, or non-small cell lung cancer from January 1, 2011, to December 31, 2016, in the National Cancer Database, a hospital-based registry capturing more than 70% of incident cancer diagnoses in the United States. Data were analyzed from March 8 to August 15, 2019. Residence in a state that expanded Medicaid on January 1, 2014. The primary outcomes were insurance status, cancer stage, and timely treatment within 30 and 90 days of diagnosis. A total of 925 543 patients (78.6% women; mean [SD] age, 55.0 [6.5] years; 14.2% black; and 5.7% Hispanic) had a new diagnosis of invasive breast (58.9%), colon (14.6%), or non-small cell lung (26.5%) cancer; 48.3% resided in Medicaid expansion states and 51.7% resided in nonexpansion states. Compared with nonexpansion states, the percentage of uninsured patients decreased more in expansion states (adjusted DID, -0.7 [95% CI, -1.2 to -0.3] percentage points), and the percentage of early-stage cancer diagnoses rose more in expansion states (adjusted DID, 0.8 [95% CI, 0.3 to 1.2] percentage points). Among the 848 329 patients who underwent cancer-directed therapy within 365 days of diagnosis, the percentage treated within 30 days declined from 52.7% before to 48.0% after expansion in expansion states (difference, -4.7 [95% CI, -5.1 to -4.5] percentage points). In nonexpansion states, this percentage declined from 56.9% to 51.5% (difference, -5.4 [95% CI, -5.6 to -5.1] percentage points), yielding no statistically significant DID in timely treatment associated with Medicaid expansion (adjusted DID, 0.6 [95% CI, -0.2 to 1.4] percentage points). This study found that, among patients with incident breast, colon, and lung cancer, Medicaid expansion was associated with a decreased rate of uninsured patients and increased rate of early-stage cancer diagnosis; no evidence of improvement or decrement in the rate of timely treatment was found. Further research is warranted to understand Medicaid expansion's effect on the treatment patterns and health outcomes of patients with cancer.
Highlights
The Patient Protection and Affordable Care Act (ACA) expanded Medicaid eligibility in participating states to nonelderly adults with incomes at or below 138% of the federal poverty level
Among the 848 329 patients who underwent cancer-directed therapy within 365 days of diagnosis, the percentage treated within 30 days declined from 52.7% before to 48.0% after expansion in expansion states. This percentage declined from 56.9% to 51.5%, yielding no statistically significant DID in timely treatment associated with Medicaid expansion
Key Points Question Three years after implementation of the Patient Protection and Affordable Care Act, was Medicaid expansion associated with changes in insurance status and cancer stage at diagnosis without delaying time to treatment?. In this cross-sectional study of 925 543 patients with incident breast, colon, and lung cancer, Medicaid expansion was associated with a decreased rate of uninsured patients and an increased rate of early-stage cancer diagnosis; it was not associated with changes in the rate of timely treatment
Summary
The Patient Protection and Affordable Care Act (ACA) expanded Medicaid eligibility in participating states to nonelderly adults with incomes at or below 138% of the federal poverty level. More than 20 million US residents have gained insurance coverage.[1] These expansions have been associated with improved access to care, affordability, and, for certain surgical procedures and medical conditions, health outcomes.[2,3,4,5,6,7,8] studies have suggested unintended consequences, such as lengthened wait times,[2,6] and debate about the overall effect of the expansions at the state and federal levels is ongoing.[9]. Given an already strained oncology workforce,[19,20] Medicaid expansion might lengthen wait times and exacerbate TTI for patients with cancer Because such patients are vulnerable to treatment delays, an understanding of this potential unintended consequence is critical for policy makers weighing the merits of the ACA’s Medicaid expansion. The objectives of this study were to examine changes in insurance status, stage at diagnosis, and timely treatment associated with Medicaid expansion among patients with incident breast, colon, and lung cancer
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