Medicaid Expansion Research Articles

Medicaid expansion and stage of cervical cancer diagnosis

Medicaid expansion and stage of cervical cancer diagnosis

The effect of Medicaid expansion on the receipt of guideline-concordant care among patients with cervical cancer in the United States: A difference-in-difference analysis of the National Cancer Database

The effect of Medicaid expansion on the receipt of guideline-concordant care among patients with cervical cancer in the United States: A difference-in-difference analysis of the National Cancer Database

The impact of Medicaid expansion on cervical cancer outcomes

The impact of Medicaid expansion on cervical cancer outcomes

Impact of Medicaid expansion on cervical cancer screening rates: A state-specific difference in difference analysis

Impact of Medicaid expansion on cervical cancer screening rates: A state-specific difference in difference analysis

Pregnancy-Related Mortality Disparities During the COVID-19 Pandemic.

Objectives. To compare pregnancy-related mortality ratios (PRMRs) associated with COVID-19 by race/ethnicity, by region of residence, and in states with and without Medicaid expansion. Methods. We used 2020-2021 data from the US Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research in our analysis. We stratified PRMRs by race/ethnicity, census regions, and Medicaid expansion and nonexpansion states. Results. The 2020-2021 PRMR was 40.3 per 100 000 live births. American Indian/ Alaska Native pregnant people had the greatest PRMR, followed by non-Hispanic Blacks and non-Hispanic Native Hawaiians/other Pacific Islanders. PRMRs associated with COVID-19 in the southern region were at least 2 times higher than in other regions and were highest for all pregnant people in the various racial/ethnic groups. PRMRs associated with COVID-19 were lower in Medicaid expansion states than in nonexpansion states. Conclusions. The US COVID-19 epidemic exacerbated racial and ethnic disparities in pregnancy-related mortality. Public Health Implications. The alarming increase in disparities among racial and ethnic pregnant people during the COVID-19 pandemic underscores the need to address social determinants of health at the structural level. (Am J Public Health. Published online ahead of print October 24, 2024:e1-e8. https://doi.org/10.2105/AJPH.2024.307814).

Association of Medicaid Expansion With Timely Receipt of Treatment and Survival Among Patients With HR-Negative, HER2-Positive Breast Cancer.

Hormone receptor (HR)-negative, HER2-positive (also called HER2-enriched) breast cancer has no worse prognosis than other breast cancers if it is treated with HER2-targeted therapy. Medicaid expansion under the Affordable Care Act (ACA) has been shown to be associated with improved access to care and outcomes for many cancers, but its association with receipt of care for HR-negative, HER2-positive breast cancer is unknown. We examined the association of Medicaid expansion with receipt of guideline-concordant treatment, time to treatment initiation, and survival among nonelderly women newly diagnosed with HR-negative, HER2-positive breast cancer. Women aged 18 to 62 years newly diagnosed with HR-negative, HER2-positive breast cancer between 2010 and 2018 were identified from the National Cancer Database. Outcomes included receipt of stage-based guideline-concordant treatment, timely initiation of treatment (<30 days, <60 days, <90 days from diagnosis), and stage-specific 2-year overall survival. A difference-in-differences (DID) analytic approach compared outcome changes following Medicaid expansion in expansion versus nonexpansion states. Multivariable linear probability models were used to estimate treatment outcomes, and flexible parametric survival models were used to evaluate survival, adjusting for sociodemographic and clinical confounders. A total of 31,401 patients were included. Medicaid expansion was associated with an increase of 0.58 percentage points (ppt; 95% CI, 0.01-1.16) in receipt of guideline-concordant treatment overall, a 2.43-ppt (95% CI, 0.68-4.18) increase in initiating guideline-concordant treatment <60 days after diagnosis, and a 1.17-ppt (95% CI, 0.02-2.32) increase in 2-year survival rate. The increase in 2-year survival associated with Medicaid expansion was most prominent for patients with stage III disease (DID, 3.81; 95% CI, 0.82-6.80). Medicaid expansion was associated with improved care and survival for patients with HR-negative, HER2-positive breast cancer, an aggressive cancer type for which prognosis largely depends on access to effective treatment.

The Effect of Medicaid Expansion on Access to Anti-incontinence Surgery

Importance Medicaid expansion broadened access to care; however, limited data about the effect on access to anti-incontinence surgical procedures exist. Objective Since the Affordable Care Act (ACA) Medicaid expansion in 2014, some regions have had more states adopt expansion (NE—Northeast, W—West) than other regions (S—South, MW—Midwest). We aimed to determine if the proportion of Medicaid funded anti-incontinence procedures increased after Medicaid expansion and whether increases were different by U.S. region. Study Design This was a retrospective cohort study. Results The 2012–2018 Healthcare Cost and Utilization Project National Inpatient Sample was reviewed for anti-incontinence surgical procedures. Medicaid supported surgical procedures were compared by region and year, and among marginalized populations. During the study period 66,510 surgical procedures were performed. Medicaid as a primary payer for anti-incontinence procedures increased from 10% to 12% (P = &lt;0.001) between 2012 and 2018. The percentage of Medicaid supported procedures performed in the NE (13%) and W (17%) were greater than MW (9%) and S (8%). Procedures among Black, Hispanic or lowest income quartile patients were lowest in the S and did not increase after expansion during the study period (2012 vs 2018, all P = NS). When controlling for confounders, the MW (odds ratio [OR] 0.58; 95% CI 0.46–0.74) and S (OR 0.33; 95% CI 0.26–0.42) were less likely to have Medicaid covered surgical procedures compared to the NE and W (OR 1.04; 95% CI 0.84–1.29). Conclusions Nationally, the percentage of Medicaid-supported anti-incontinence procedures increased after expansion. Northeast and W access to procedures increased, and access by marginalized populations broadened, while the S and MW had the most limited proportion of anti-incontinence surgical procedures covered by Medicaid.

Impact of the Affordable Care Act and Medicaid Expansion Among Patients With HIV-Associated Aggressive B-Cell Non-Hodgkin Lymphomas.

To study the influence of the Affordable Care Act (ACA) policy and its Medicaid expansion on insurance status and survival in patients with HIV with aggressive lymphoma. We used the National Cancer Database, a hospital-based national registry, to identify adults age 18-64 years with HIV-associated aggressive B-cell non-Hodgkin lymphomas (HIV-a-B-NHLs), diagnosed during 2007 to 2016. Survival analysis was performed on a subset of patients with HIV-a-B-NHL for whom location data were available who resided in Medicaid expansion-adopted and nonadopted states. Using a quasi-experimental difference-in-difference model, the difference in adjusted 2-year survival rates obtained with a flexible parametric Weibull model was compared for states that adopted the Medicaid expansion of ACA against those that did not adopt the expansion. We identified 8,231 patients with HIV-a-B-NHL and 50,650 non-HIV patients with a-B-NHL. We found that a lower proportion of individuals were uninsured at diagnosis in the expansion states compared with nonexpansion states. We also found that the ACA policy adoption led to a reduction in the proportion of uninsured individuals with HIV-a-B-NHL in expansion states of 34.9%, compared with 15.9% in non-expansion-adopted states. There was a statistically significant improvement in the 2-year survival rate among patients with HIV-a-B-NHL in the expansion compared with nonexpansion states with the adoption of ACA (7.17% v 1.58%, P = .02). Using a novel quasi-experimental model, we found that the ACA policy corresponded with a greater survival improvement in patients with HIV-a-B-NHL within Medicaid expansion-adopted states compared with nonexpansion states. We believe that this evidence should be taken into consideration in future policy making.

Identifying and Characterizing Models of Substance Use Treatment in Outpatient Substance Use Treatment Facilities.

Given that individuals with substance use disorders (SUDs) have a variety of needs beyond substance use, it is critical to examine the comprehensiveness of services offered within outpatient SUD treatment facilities, where many individuals with SUDs receive care. This study's objective is to develop clusters of services offered, and assess organizational, policy, and environmental characteristics associated with having a more comprehensive treatment model. We conducted a principal component analysis (PCA) using data on SUD treatment facilities (n=8, 197) from the 2022 Mental Health and Addiction Treatment Tracking Repository, a national database of SUD treatment facilities. We applied a K-means cluster analysis on the generated components to cluster facilities by service offerings, and calculated the mean for different organizational, policy and environmental characteristics for each cluster. We retained five components from the PCA which represented the availability of different services (Pharmacotherapies, Infectious Disease and Harm Reduction, Supportive and Social Determinant of Health (SDOH) Services, Psychosocial Services, and General Healthcare.) The cluster analysis resulted in five SUD service models, with the most comprehensive having the highest percentage of accredited and Medicaid-accepting facilities, and facilities that were government-operated and located in a Medicaid expansion state, and the least comprehensive having lowest percentage of accredited, licensed and Medicaid-accepting facilities, and the highest percentage of private for-profit facilities. Our study found that SUD treatment facilities varied in the availability of five treatment components, but more comprehensive service models had a higher percentage of facilities that were licensed, accredited, and accepting Medicaid.

Expansion of Medicaid Coverage of Continuous Glucose Monitor Reduces Health Disparity in Children and Young Adults With Type 1 Diabetes.

Continuous glucose monitor (CGM) usage improves glycemia in people with type 1 diabetes (PWD) and is accepted as the standard of care. The CGM utilization is lower in patients with public insurance and minorized ethnicities. In 2022, California Medicaid reduced its barriers to obtaining CGM coverage for PWD. It is unknown whether this policy change is sufficient to increase CGM usage. We hypothesize that the change in Medicaid coverage improved CGM uptake in children and young adults with T1D. Data were extracted from electronic medical record of a large urban children's hospital in 2021 and 2022. The CGM usage was determined based on clinician documentation or the presence of CGM downloads. Kruskal-Wallis tests, Wald tests, and χ2 tests were used to test hypothesis (P < .05). Mixed effects logistical regression analyses were performed. We included 878 and 892 PWD (age ≤ 21 years) in 2021 and 2022, respectively. In 2022, Medicaid insured 59.3% of patients. Between 2021 and 2022, CGM usage did not change for privately insured patients (84%) but increased from 41% to 58% for patients receiving Medicaid. In our mixed effects logistic regression model, CGM usage was higher in 2022 and in English speakers. Public insurance, black race, and patients' age were negatively associated with CGM usage. Our results suggest that Medicaid expansion of CGM coverage increases its utilization for pediatric PWD but did not eliminate the disparity. Future studies are needed to identify barriers that preclude equity in technology uptake.

Medicaid managed care restrictions on medications for the treatment of opioid use disorder.

To examine whether Medicaid managed care plan (MCP) utilization management policies for buprenorphine-naloxone and injectable naltrexone are related to key state Medicaid program policy decisions. We abstracted data on state Medicaid regulatory and policy information from publicly available sources and publicly available insurance benefit documentation from all 241 Medicaid MCPs operating in 2021. In this cross-sectional study, we used bivariate and multivariate analyses to examine whether Medicaid MCP prior authorization and quantity limits on receipt of buprenorphine and injectable naltrexone were associated with key state Medicaid choices to leverage federal funds to expand coverage and eligibility (Medicaid expansion, 1115 waivers) and to regulate Medicaid MCPs (uniform preferred drug lists, medical loss ratio remittance). Models were adjusted for MCP characteristics, including profit status, behavioral health contracting arrangement, National Committee for Quality Assurance accreditation, size, market share, and state opioid overdose death rates. Average marginal effects (AME) were reported. Utilization management was common among MCPs, and restrictions were more commonly applied to buprenorphine than injectable naltrexone, despite its higher cost. States that required MCPs to comply with utilization management policies stipulated in a uniform preferred drug list were more likely to require prior authorization for buprenorphine (AME: 0.29, 95% CI: 0.15-0.42) and injectable naltrexone (AME: 0.25, 95% CI: 0.12-0.38). MCPs in states that required plans to pay back earnings above a certain threshold were less likely to require prior authorization for buprenorphine (AME: -0.30, 95% CI: -0.43 to -0.18). Restrictions on medications for opioid use disorder are widespread among MCPs and vary by medication. State Medicaid regulatory and policy characteristics were strongly linked to MCPs' utilization management approaches. State Medicaid policy and contracting approaches may be levers to eliminate utilization management restrictions on medications for opioid use disorder.

Robotic availability, not payor status, determines access to robotic emergency general surgery hernia repair in California and Florida.

Previous studies have demonstrated that access to robotic surgery is influenced by socioeconomic factors, including insurance status. The 2010 Affordable Care Act established an avenue for states to expand Medicaid coverage, which has increased access to surgical care for many conditions. We hypothesized that socioeconomic disparities in access to robotic repair of non-elective emergency general surgery (EGS) hernias are less prevalent in California, a Medicaid expansion state, compared to Florida, which has not adopted Medicaid expansion. The 2021 California and Florida State Inpatient Databases were used to identify all EGS admissions with an ICD-10 procedure code for ventral or inguinal hernia repair. Elective procedures and those with concurrent unrelated abdominal procedures were excluded. Patient demographics, comorbidity burden, payor status, and income quartile were abstracted. Aggregation of hospital data identified high-volume trauma, robotic, and EGS centers. There were 15,683 EGS hernia procedures of which 11% underwent robotic repair: 14% in Florida and 8% in California. On multivariable logistic regression, older age, male sex, lower income, and Medicare insurance were associated with reduced odds of robotic hernia repair in California, but not in Florida, despite an uninsured rate of 10%. The greatest predictor of robotic surgery in both states was treatment at a robotic surgery center. Overall, accounting for patient- and hospital-level factors, hernia surgeries in Florida were more likely to involve robotics (OR 1.61, CI 1.42-1.81, p < 0.001) compared to California. There were fewer disparities in access to EGS robotic hernia repairs in Florida than in California. This suggests that robotic surgery access for EGS hernia repairs is primarily determined by institutional adoption of robotic surgery, not income or payor status. Compared to California, Florida appears to have greater market penetration of robotic surgery, which has increased access to robotic EGS for all patients.

The impact of Medicaid expansion under the Affordable Care Act on HIV care continuum outcomes across the United States.

HIV care continuum outcome disparities by health insurance status have been noted among people with HIV (PWH). We therefore examined associations between state Medicaid expansion and HIV outcomes in the United States. Adults (≥18 years) with ≥1 visit in NA-ACCORD clinical cohorts from 2012-2017 contributed person-time annually between first and final visit or death; in each calendar year, clinical retention was ≥2 completed visits > 90 days apart, antiretroviral therapy (ART) receipt was receipt of ≥3 antiretroviral agents, and viral suppression was last measured HIV-1 RNA < 200 copies/mL. CD4 at enrollment was obtained within 6 months of enrollment in cohort. Difference-in-difference (DID) models quantified associations between Medicaid expansion changes (by state of residence) and HIV outcomes. Across 50 states, 87 290 PWH contributed 325 113 person-years of follow-up. Medicaid expansion had a substantial positive effect on CD4 at enrollment (DID = 93.5, 95% CI: 52.9, 134 cells/mm3), a small negative effect on proportions clinically retained (DID = -0.19, 95% CI: -0.037, -0.01), and no effects on ART receipt (DID = 0.001, 95% CI: -0.003, 0.005) or viral suppression (DID = -0.14, 95% CI: -0.34, 0.07). Medicaid expansion had a positive effect on CD4 at entry, suggesting more timely HIV testing and care linkage, but generally null effects on downstream HIV care continuum measures.

Primary care need and engagement by people with criminal legal involvement: Descriptive and associational analysis using retrospective data on the entire population ever detained in one southeastern U.S. county jail 2014-2020.

More than 7 million people are released each year from U.S. jails or prisons, many with chronic diseases that would benefit from primary care in their returning communities. The objective of this study was to provide an in-depth, payer-agnostic description and associational analysis of primary care need and utilization by all individuals ever detained in one county detention facility over a 7-year period. Detention records 2014-2020 were merged with data from an electronic health record with excellent coverage of local primary care, emergency, and hospital services. We found low primary care participation for the group as a whole, with under three quarters of those with serious chronic diseases ever seeing a primary care provider over a 7-year period and less than half ever having a year with more than one visit. Multivariable regression models estimated associations between individual characteristics (demographic, detention-related, and clinical) and ever having access to primary care (logistic) and the number of primary care visits (zero-inflated negative binomial). We found that having more jail bookings was associated with fewer primary care visits, but not one-time access, even controlling for time out of community, age, insurance, and other demographic characteristics. This finding was driven by subgroups with chronic disease such as hypertension, obstructive lung disease, and diabetes, who most need regular primary care. Being Black retained an independent effect, even controlling for bookings and other variables, and was also associated with fewer primary care visits, though not one-time access. To promote primary care utilization among individuals who have the combined challenges of repeated jail involvement and chronic disease, it is crucial to focus on engagement, as much as formal access. Access to health insurance alone will not resolve the problem; Medicaid expansion should be coupled with specialized, tailored support to promote engagement in primary care.

Spillover effects of Medicaid expansion on Medicare: Evidence from administrative data

AbstractThe 2014 Medicaid expansion excluded Americans who were 65 years old and older, but they could still be affected via spillover effects. Using Medicare administrative data, we test for spillovers in Medicare spending and Medicaid coverage among low‐income Medicare beneficiaries. We analyze two cohorts: those under 65 in 2014, who could have been induced by the expansion to take up Medicaid before joining Medicare; and those 65 or older in 2014, whose Medicaid eligibility was never affected by the expansion. We only find spillovers for the under‐65 cohort, where Medicare spending fell and Medicaid coverage increased, with no measurable adverse effect on mortality. Combined with a null effect for the over‐65 cohort, these facts suggest Medicare beneficiaries were not crowded out of health care by the expansion. Instead, those under‐65 cohort satisfied “pent‐up” demand via Medicaid, consuming care they would have otherwise obtained later under Medicare.

340B Participation and Safety Net Engagement Among Federally Qualified Health Centers

The 340B program provides discounts on outpatient drugs to certain hospitals and federally supported clinics (covered entities) that can be used to generate revenue to fund safety net care. While numerous studies have found no association between 340B and safety net care provision for most hospital covered entities, less is known about whether federally qualified health centers (FQHCs), the largest group of covered entities after hospitals, use the program to enhance safety net care. To assess whether a proxy for 340B revenue was associated with increased safety net care provision among FQHCs. This descriptive, retrospective cohort study examined care provided from 2005 to 2022 by 1468 FQHCs that submitted to the Health Resources and Services Administration Uniform Data System. FQHC and year-level fixed effects were included, as well as a control for differential Medicaid expansion over time. The data were analyzed between March and December 2023. One-year lagged number of locations registered to dispense or administer 340B-discounted drugs (registered locations), which included child sites, in-house pharmacies, and contract pharmacies in the 340B Outpatient Pharmacy Affairs Database. Natural logarithm of patient volume by payer, low-income status, and use of enabling services. Natural logarithm of visits in which low-profit preventive services were provided. An additional registered location was associated with increased patient volume, especially for uninsured (0.4%; 95% CI, 0.3%-0.5%) and privately insured (0.4%; 95% CI, 0.2%-0.5%) patients and low-income (0.4%; 95% CI, 0.2%-0.6%), unhoused (0.3%; 95% CI, 0.1%-0.5%), and non-English-speaking (0.3%; 95% CI, 0.1%-0.5%) patients. An additional registered location was associated with increased visits with an HIV test (0.7%; 95% CI, 0.4%-0.9%), serum lead test (0.8%; 95% CI, 0.6%-1.1%), seasonal influenza shot (0.4%; 95% CI, 0.3%-0.5%), Papanicolaou smear (0.5%; 95% CI, 0.4%-0.7%), and tobacco cessation counseling (1.0%; 95% CI, 0.5%-1.4%). Across the study period, the average annual increase in locations was 1.5. The results of this cohort study suggest that there are statistically significant increases in the provision of low-profit but high-value preventive services and care to safety net populations (those who lack insurance, have a low income, or require enabling services) and that, like public hospitals, FQHCs might use 340B revenues to enhance safety net care. This finding may inform debates on the 340B program by supporting differential 340B reforms across hospital and nonhospital covered entities.

Community Benefit and Tax-Exemption Levels at Non-Profit Hospitals Across U.S. States.

To assess the association between state policies and sociodemographic characteristics and state mean fair share spending at non-profit hospitals. Fair share spending is a hospital's charity care and community investment less the estimated value of their tax-exempt status. Hospitals with non-profit status in the United States are exempt from paying taxes. In return, they are expected to provide community benefits by subsidizing medical care for those who cannot pay and investing in the health and social needs of their community. We used a multivariable linear regression model to determine the association of state-level sociodemographics and policies with state-level mean fair share spending in 2019. Fair share spending data was obtained from the Lown Institute. We found no association between the percentage of people living in poverty, in rural areas, or U.S. region and fair share spending. Similarly, there was no association found for state minimum community benefit and reporting requirements. The state percentage of racial/ethnic minorities was associated with higher mean fair share spending [+$1.48 million for every 10% increase (95% CI: 0.01 to 2.96 million)]. Medicaid expansion status was associated with a 6.9-million-dollar decrease (95% CI: -10.4 to -3.3 million). State-level community benefit policies have been ineffective at raising community benefit spending to levels comparable to the value of non-profit hospital tax-exempt status.

Association between Medicaid expansion and stage at diagnosis and treatment rates of non-small cell lung cancer.

87 Background: Lung cancer is a leading cause of cancer mortality in the United States, with Non-small cell lung cancer (NSCLC) being the most common subtype. Under the Affordable Care Act, 39 states adopted Medicaid Expansion (ME) in 2014, while 12 did not. ME improved insurance coverage and lung cancer screening rates. This study examined the association between ME and NSCLC stage at diagnosis and treatment rates. Methods: We performed a retrospective observational study using Surveillance, Epidemiology, and End Results (SEER) database including patients aged 55-64 diagnosed with NSCLC from 2007 to 2021. Multivariate logistic regression analysis was performed to compare the odds of Early NSCLC diagnosis (Stages 1 and 2) and odds of treatment for early NSCLC between ME states and non-ME states before and after 2014. Results: During the study period, 191,785 patients were diagnosed with NSCLC, of which 42,338 were early NSCLC. The odds of early NSCLC diagnosis and treatment in early NSCLC were similar in ME and non-ME states before 2014. After 2014, the odds of early NSCLC diagnosis were significantly higher in ME states [AOR-1.53 (1.45-1.63)] compared to non-ME states [AOR-1.34 (1.25-1.44)]. However, there was no significant difference in odds of treatment for early NSCLC in ME states [1.36 (1.01 -1.81) and non-ME states 1.25 (0.93-1.68) after 2014. Conclusions: We conclude that ME is associated with increased odds of early-stage diagnosis of NSCLC. However, the odds of receipt of treatment were not affected. These findings highlight the benefits of ME as an effective strategy to improve access to care, but also underscore that other barriers to receiving treatment exist despite early diagnosis. Further studies are warranted to identify the barriers and potential limitations of policy change to improve outcomes. Logistic analysis for odds of early-stage NSCLC diagnosis and odds of treatment in early NSCLC. Early NSCLC Diagnosis Odds Ratio p-value 95% Confidence Interval Non – ME States (Pre- Expansion) 1.00 (Reference) Non – ME States (Post- Expansion) 1.34 0.00 1.25 - 1.44 ME States (Pre- Expansion) 1.04 0.16 0.98 - 1.11 ME States (Post- Expansion) 1.53 0.00 1.45 - 1.63 Treatment of Early NSCLC Non - ME States (Pre- Expansion) 1.00 (Reference) Non-ME States (Post- Expansion) 1.25 0.13 0.93-1.68 ME States (Pre- Expansion) 1.40 0.05 1.00 - 1.95 ME States (Post- Expansion) 1.36 0.04 1.01- 1.81 NSCLC- Non-Small Cell Lung Cancer, ME- Medicaid Expansion.

Impact of Medicaid expansion on receipt of pancreatectomy in early-stage pancreatic cancer.

106 Background: Pancreatic cancer is estimated to rank third in cancer-related mortality in 2024 by the American Cancer Society. Despite the proven increase in 5-year survival with pancreatectomy in Early Pancreatic Cancer (EPC), it is nationally underutilized. Medicaid expansion (ME) under the Affordable Care Act is associated with gains in insurance coverage and early cancer diagnosis in patients with pancreatic cancer. However, its impact on the receipt of pancreatectomy in EPC remains unclear. In this study, we looked at the impact of ME on the uptake of pancreatectomy in EPC. Methods: We performed a retrospective observational study using the Surveillance, Epidemiology, and End Results (SEER) database, which included patients diagnosed with EPC (Stage 1 and Stage 2) between 2006 and 2021. Multivariate logistic regression was performed to ascertain the effects of ME on the uptake of pancreatectomy in patients with EPC in states that expanded vs. states that did not, with 2014 as an inflection point for policy implementation. Results: During this study period, 29,384 were diagnosed with EPC, 10,777 patients were diagnosed pre-ME and 18,607 post-ME. The odds of receipt of pancreatectomy for EPC in non-expansion states after 2014 was 20% higher than before 2014. However, this was not statistically significant [AOR – 1.20 (0.98-1.48)]. There was also no significant difference between the odds of receipt of treatment for EPC for ME states before [AOR- 1.27 (1.06-1.51)] and after [AOR-1.21 (1.01-1.44)] 2014. Increasing age, male sex, Black and Hispanic race, having an income lower than $65,000, and living in less populated areas were all associated with lower odds of receipt of pancreatectomy in EPC. Conclusions: ME was not associated with increased uptake of pancreatectomy in EPC. However, prior studies have shown that ME is linked to an earlier stage at pancreatic cancer diagnosis. This suggests that despite earlier diagnosis, other barriers to receiving treatment exist. Future studies are warranted to identify the limitations of policy change to improve outcomes of such aggressive cancer. Logistic regression for receipt of pancreatectomy in early-stage pancreatic cancer. Receipt of Surgical Treatment for Early Pancreatic cancer Adjusted Odds Ratio (95% Confidence Interval) Non- ME States (Pre-Expansion) 1.00 (Reference) Non- ME States (Post -Expansion) 1.20 (0.98-1.48) ME States (Pre-Expansion) 1.27 (1.06-1.51) ME States (Post-Expansion) 1.21 (1.01-1.44) ME- Medicaid expansion.

Associations of Medicaid expansion with stage at diagnosis, timely initiation and receipt of guideline-concordant treatment, and survival among individuals newly diagnosed with non-small cell lung cancer.

47 Background: Medicaid expansion under the Patient Protection and Affordable Care Act improved health insurance coverage among patients with cancer. Individuals with non-small cell lung cancer (NSCLC) may benefit from Medicaid expansion throughout the cancer control continuum. This study examined the associations of Medicaid expansion with stage at disease diagnosis, timely initiation and receipt of guideline-concordant treatment, and five-year overall survival among individuals with NSCLC. Methods: We identified individuals newly diagnosed at age 18-64 with stages I-IV first primary NSCLC between January 1, 2008 and December 31, 2019 in 50 states and Washington, D.C. from the National Cancer Database (n=332,368). We examined the associations of Medicaid expansion with (1) diagnosis stage, which was categorized into early (I&amp;II) and late (III&amp;IV); (2) timely initiation of guideline-concordant treatment within 30 days after cancer diagnosis (yes/no); (3) receipt of guideline-concordant treatment (yes/no) derived from the National Comprehensive Cancer Network cancer treatment guidelines; and (4) five-year overall survival. We applied a difference-in-differences (DD) approach to examine the changes in study outcomes associated with Medicaid expansion, controlling for key sociodemographic and clinical factors. Results: The percentage of early-stage diagnoses increased from 23.1% pre-expansion to 31.9% post-expansion in expansion states and from 22.3% to 29.5% in non-expansion states, translating to greater increase of 1.7 (95% confidence interval (CI): 0.3-3.1) percentage points (ppt) in expansion states after adjustment (Table). Medicaid expansion was also associated with greater increases in timely initiation of guideline-concordant care (DD: 1.6 (95% CI: 0.1-3.1) ppt) and five-year overall survival (DD: 1.3 (95% CI: 0.7-1.9) ppt). Conclusions: Medicaid expansion may improve access to NSCLC care and outcomes across the cancer control continuum, from early-stage diagnosis, treatment initiation, and overall survival. Association of Medicaid expansion and study outcomes among NSCLC patients. Expansion States Non-expansion States Pre-ME Post-ME Difference Pre-ME Post-ME Difference DD Adjusted DD Early-stage diagnosis 23.1 31.9 8.7 (7.4 to 10.1) 22.3 29.5 7.2 (6.2 to 10.1) 1.5 (-0.1 to 3.2) 1.7 (0.3 to 3.1) Timely initiation of guideline-concordant care 31.3 27.5 -3.9 (-5.3 to -2.4) 33.4 27.8 -5.6 (-6.24 to -2.4) 1.7 (0.1 to 3.3) 1.6 (0.1 to 3.1) Receipt of guideline-concordant care 65.2 68.2 2.9 (1.8 to 4.0) 62.9 66.4 3.5 (2.7 to 4.0) -0.6 (-2.0 to 0.8) -0.2 (-1.7 to 1.3) Five-year survival 21.3 34.8 13.5 (13.1 to 13.9) 18.6 30.2 11.6 (11.1 to 12.2) 1.9 (1.2 to 2.5) 1.3 (0.7 to 1.9) Abbreviation: ME, Medicaid expansion.