Medicaid expansion and cancer stage at diagnoses during the COVID-19 pandemic in the United States.

Abstract

1526 Background: Substantial cancer underdiagnosis, especially for early-stage diseases, occurred during the COVID-19 pandemic in the US in 2020. The Affordable Care Act expanded Medicaid to nonelderly adults with income up to 138% Federal Poverty Level in states that opted in, potentially facilitating residents’ access to care during pandemic-related financial and employment instability, thus aiding in timely detection of cancer. This study examines the association of Medicaid expansion with changes in cancer stage at diagnosis during the COVID-19 pandemic. Methods: Adults aged 18-64 years newly diagnosed with cancer in 2019 and 2021 were identified from the National Cancer Database. Year 2020 was excluded to avoid confounding from distinct geographic patterns of COVID-19 infections. A difference-in-differences (DD) approach was used to compare the changes in proportions of patients diagnosed at stage I/II in 2021 vs 2019 between Medicaid expansion states and non-expansion states. Adjusted DD estimates were calculated with linear probability models and stratified by key sociodemographic factors and cancer type. Results: A total of 427,368 adults newly diagnosed with cancer in 2019 and 393,961 in 2021 were identified. Patients diagnosed with stage I/II decreased nationwide, however, decreases were larger in non-expansion states (from 58.3% in 2019 to 56.9% in 2021) compared to expansion states (61.4% in 2019 to 60.7% in 2021), leading to a DD of 0.92 percentage points in early-stage cancer diagnosis associated with Medicaid expansion (95% CI =0.46-1.38). The association was strongest among individuals aged 18-44 years (DD=1.46, 95% CI=0.42-2.49), men (DD=1.46, 95% CI=0.73-2.19), those living in most socioeconomically deprived areas (DD=1.40, 95% CI=0.41-2.40) and nonmetropolitan areas (DD=1.82, 95% CI=0.56-3.09). When stratified by cancer type, the largest associations were seen for esophageal cancer (DD=3.86, 95% CI=0.26-7.45) and prostate cancer (DD=2.81, 95% CI=1.43-4.18). Conclusions: Substantial cancer underdiagnosis and declines in proportion of early-stage diagnoses continued nationwide in 2021, the second year of the COVID-19 pandemic. However, the pattern was worse in non-expansion states, suggesting a protective effect of Medicaid expansion on cancer early diagnosis during the public health emergency. Findings may inform policy makers and the public in the 10 states that have yet to expand Medicaid eligibility.