Post-expansion Period Research Articles

The Role of Medicaid Expansion on the Receipt of Adjuvant Chemotherapy in Patients With Lung Cancer

ObjectiveWe aimed to utilize a nationally representative database to study the effect of Medicaid expansion on the receipt of adjuvant chemotherapy in eligible patients. Materials and MethodsRetrospective review of the National Cancer Database (NCDB) was performed between 2006 and 2019. Patients with clinical T1-T3, N1, and M0 were included. Patients with nodal disease or tumors > 4 cm were eligible for adjuvant therapy. Demographic and clinical information were collected. A difference-in-difference analysis was performed to compare changes in the rate of adjuvant chemotherapy. ResultsTotal 9954 eligible patients were treated in states that expanded Medicaid coverage in January 2014 or later, with 4809 patients treated in the pre-expansion years (2012-2013) and 5145 patients treated in the postexpansion years (2017-2018). Following Medicaid expansion, eligible patients were more likely to receive adjuvant therapy (70.2% vs. 62.3%; P < .001). Compared with the pre-expansion period, patients who received adjuvant therapy were more likely to use Medicaid insurance postexpansion (7.8% vs. 5%, P < .001). Among patients using Medicaid coverage only, a greater percentage started adjuvant therapy within 8 weeks of resection following Medicaid expansion (46.6% vs. 38.3%, P = .048). The observed difference-in-difference in the change in adjuvant therapy rate from the pre-expansion period to the postexpansion period between expansion and nonexpansion states was 1.25% (95% Bootstrap CI −0.36% to −3.18%). There was a modest survival benefit in expansion states postexpansion. ConclusionMedicaid expansion appears to be associated with increased access to care, as shown by the increased receipt of adjuvant systemic therapy in eligible patients.

Medicaid expansion in California and breast cancer incidence across neighborhoods with varying social vulnerabilities.

To investigate changes in breast cancer incidence rates associated with Medicaid expansion in California. We extracted yearly census tract-level population counts and cases of breast cancer diagnosed among women aged between 20 and 64years in California during years 2010-2017. Census tracts were classified into low, medium and high groups according to their social vulnerability index (SVI). Using a difference-in-difference (DID) approach with Poisson regression models, we estimated the incidence rate, incidence rate ratio (IRR) during the pre- (2010-2013) and post-expansion periods (2014-2017), and the relative IRR (DID estimates) across three groups of neighborhoods. Prior to the Medicaid expansion, the overall incidence rate was 93.61, 122.03, and 151.12 cases per 100,000 persons among tracts with high, medium, and low-SVI, respectively; and was 96.49, 122.07, and 151.66 cases per 100,000 persons during the post-expansion period, respectively. The IRR between high and low vulnerability neighborhoods was 0.62 and 0.64 in the pre- and post-expansion period, respectively, and the relative IRR was 1.03 (95% CI 1.00 to 1.06, p = 0.026). In addition, significant DID estimate was only found for localized breast cancer (relative IRR = 1.05; 95% CI, 1.01 to 1.09, p = 0.049) between high and low-SVI neighborhoods, not for regional and distant cancer stage. The Medicaid expansion had differential impact on breast cancer incidence across neighborhoods in California, with the most pronounced increase found for localized cancer stage in high-SVI neighborhoods. Significant pre-post change was only found for localized breast cancer between high and low-SVI neighborhoods.

The positive impact of Medicaid expansion on melanoma stage at presentation.

1533 Background: This study aims to evaluate the impact of the Affordable Care Act Medicaid expansion on melanoma stage at presentation. Methods: 12,667 non-elderly patients (age 40-64) who were newly diagnosed with melanoma and known Medicaid expansion status were identified from The National Cancer Database. We excluded patients with private insurance, Medicare, or other government or unknown insurance. The time period for the cohort spanned from 2010 to 2020 which includes pre-expansion (2010-2013) and post-expansion periods (2014-2020). Year-to-year trend analysis and difference-in-difference (DID) analysis was performed to analyze tumor staging between states with Medicaid expansion (MES) and without Medicaid expansion (non-MES) before and after the expansion. Results: Out of the 12,667 melanoma patients (56% male, 95% white), 41% of patients were uninsured and 59% had Medicaid during 2010 to 2020. The percentage of patients without insurance decreased significantly from 51% in 2010 to 16% in 2020. There were 21% of patients with stage III and 18% with stage IV melanoma. The trend of melanoma stage at presentation over the study period was shown (Table). Notably, the stage IV melanoma at presentation decreased from 21% to 17% from 2010 to 2020 in MES. In contrast, stage IV melanoma at presentation increased from 20% to 23% over the same period of time in non-MES. After adjusting for confounders, DID analysis revealed a statistically significant decrease in stage IV melanoma at presentation (DID -0.04, p &lt; 0.001) as well as a statistically significant decrease in 3 year mortality (DID -0.05, p &lt; 0.001) between MES and non-MES before and after Medicaid expansion. In addition, the use of immunotherapy in stage IV melanoma in MES was significantly higher than non-MES (47% vs 41%, p &lt; 0.001). Conclusions: The findings reveal the positive impact of Medicaid expansion on melanoma stage at presentation and suggest that improved access to healthcare services can facilitate diagnosing early-stage melanoma and decreasing mortality rate. Despite these findings, there are still 16% of patients who still do not have insurance in 2020 which indicates that continued effort is needed to improve the outcomes of these uninsured patients.[Table: see text]

Impact and Durability of the Affordable Care Act Medicaid Expansion on Lung Cancer Treatment

BackgroundMedicaid expansion began in 2014 after passage of the Affordable Care Act; however, the impact and durability of the effects on lung cancer treatment utilization are poorly defined. We aimed to determine whether there is a persistent difference in utilization of lung resection, lung biopsy, and nonoperative treatment of lung cancer in states participating in Medicaid expansion compared with states that are not. MethodsA retrospective cohort study was completed analyzing the difference in utilization between Medicaid expansion states and non-expansion states in 2012-2013, 2016-2017, and 2019. Patients diagnosed with and treated for lung cancer in the states of North Carolina and Florida (non-expansion states) and Maryland and New Jersey (expansion states) were included. A difference-in-difference (DID) analysis was used. ResultsIn the immediate postexpansion period (2016-2017), DID analysis revealed increased utilization in expansion states with an adjusted DID of 0.50 lung resections/100,000 persons (P = .002) and an adjusted DID of 0.76 lung biopsies/100,000 persons (P = .001). A persistent increase in utilization was found in the delayed postexpansion period (2019), with an adjusted DID of 0.51 lung resections/100,000 persons (P = .008) and an adjusted DID of 0.84 lung biopsies/100,000 persons (P = .021). No significant difference between groups was observed in the utilization of stereotactic body radiation therapy or chemotherapy. ConclusionsIn our cohort, Medicaid expansion was associated with increased utilization of procedural care for the management of lung cancer, including percutaneous biopsies and surgical resection.

Treatment Patterns and Survival Outcomes in Patients With Breast Cancer on Medicaid, Pre- and Post-Expansion.

The objective of this study was to evaluate the impact of Medicaid expansion on breast cancer treatment and survival among Medicaid-insured women in Ohio, accounting for the timing of enrollment in Medicaid relative to their cancer diagnosis and post-expansion heterogeneous Medicaid eligibility criteria, thus addressing important limitations in previous studies. Using 2011-2017 Ohio Cancer Incidence Surveillance System data linked with Medicaid claims data, we identified women aged 18 to 64 years diagnosed with local-stage or regional-stage breast cancer (n=876 and n=1,957 pre-expansion and post-expansion, respectively). We accounted for women's timing of enrollment in Medicaid relative to their cancer diagnosis, and flagged women post-expansion as Affordable Care Act (ACA) versus non-ACA, based on their income eligibility threshold. Study outcomes included standard treatment based on cancer stage and receipt of lumpectomy, mastectomy, chemotherapy, radiation, hormonal treatment, and/or treatment for HER2-positive tumors; time to treatment initiation (TTI); and overall survival. We conducted multivariable robust Poisson and Cox proportional hazards regression analysis to evaluate the independent associations between Medicaid expansion and our outcomes of interest, adjusting for patient-level and area-level characteristics. Receipt of standard treatment increased from 52.6% pre-expansion to 61.0% post-expansion (63.0% and 59.9% post-expansion in the ACA and non-ACA groups, respectively). Adjusting for potential confounders, including timing of enrollment in Medicaid, being diagnosed in the post-expansion period was associated with a higher probability of receiving standard treatment (adjusted risk ratio, 1.14 [95% CI, 1.06-1.22]) and shorter TTI (adjusted hazard ratio, 1.14 [95% CI, 1.04-1.24]), but not with survival benefits (adjusted hazard ratio, 1.00 [0.80-1.26]). Medicaid expansion in Ohio was associated with improvements in receipt of standard treatment of breast cancer and shorter TTI but not with improved survival outcomes. Future studies should elucidate the mechanisms at play.

Incident Kaposi sarcoma during the expansion of antiretroviral therapy eligibility in Nigeria: a retrospective cohort study

IntroductionThe expansion of antiretroviral therapy (ART) eligibility could lead to earlier initiation of Human Immunodeficiency Virus (HIV) treatment and consequently reduce the risk of HIV-associated Kaposi Sarcoma (KS). We investigated the impact of changes in the Nigerian HIV treatment guidelines on KS incidence among adults enrolled in HIV care in Nigeria.MethodsWe analyzed data of adults who enrolled for HIV care from January 2006 to December 2016 at one of Nigeria’s largest HIV treatment centers. Based on changes in HIV treatment guidelines, we classified 2006–2009 as the pre-expansion period and 2010–2016 as the post-expansion period. We used Kaplan Meier curves to compare the incidence of KS in the pre-expansion to the post-expansion period. We used Cox regression models to assess the hazard for incident KS between the two periods after adjusting for potential confounders.ResultsAmong 14,479 patients with HIV, the overall KS incidence was 2.35; 95% CI 2.01–2.74/1,000 person-years. The incidence of KS decreased from 2.53 to 1.58 per 1,000 person-years from 2006 to 2009 to 2010–2016. In models adjusting for age, sex, CD4-T cell count, and ART use, the risk for KS remained lower in 2010–2016 compared to 2006–2009. In analyses restricted to time on ART, there was no significant difference in KS incidence between HIV patients who enrolled in 2006–2009 and 2010–2016 after adjusting for age, sex, and CD4 T-cell count.ConclusionThe expansion of ART eligibility was associated with a reduced incidence of HIV-associated KS among adults initiating HIV care in Jos, Nigeria. The reduction was likely driven by earlier enrollment for HIV care and ART initiation.

Associations Between Medicaid Expansion and Mental Health Among U.S. Racial and Ethnic Groups.

The authors examined associations between Medicaid expansion and self-reported mental health by race-ethnicity, focusing on lagged associations. This retrospective, cross-sectional study used 2011-2019 data from the Behavioral Risk Factor Surveillance System. The sample included low-income, childless adults ages 25-64 years. Difference-in-differences (DID) analysis was used to estimate associations between Medicaid expansion and self-reported mental health. Lagged associations were examined by separating the postexpansion period into proximal (2014-2016) and distal (2017-2019) periods. In the overall sample (N=327,248), Medicaid expansion was associated with a reduction in the mean number of self-reported past-month poor mental health days (DID=-0.12, 95% CI=-0.21 to -0.03), after adjustment for covariates. The expansion was associated with significant reductions in past-month poor mental health days for the following groups: non-Hispanic White (DID=-0.18, 95% CI=-0.29 to -0.07), non-Hispanic Asian (DID=-1.15, 95% CI=-1.37 to -0.93), non-Hispanic other (DID=-0.62, 95% CI=-1.03 to -0.21), and Hispanic (DID=-0.48, 95% CI=-0.73 to -0.23). The non-Hispanic Black group had a significant increase in past-month poor mental health days (DID=0.27, 95% CI=0.06 to 0.49), and no significant change was noted for the American Indian or Alaska Native (AIAN) group. Improvements in mental health observed at the beginning of the policy implementation (proximal period) were not sustained over time for some racial-ethnic minority groups. Although Medicaid expansion improved mental health for the overall sample, some racial-ethnic disparities were detected. The negative and insignificant associations for the non-Hispanic Black and AIAN groups, respectively, highlight the need to better understand why the Medicaid expansion affected racial-ethnic groups differently.

Medicaid expansion, chemotherapy delays, and racial disparities among women with early-stage breast cancer.

Medicaid expansion under the Affordable Care Actextends eligibility for participating states and has been associated with improved outcomes by facilitating access to care. Delayed initiation of adjuvant chemotherapy is associated with worse outcomes among patients with early-stage breast cancer (BC). The impact of Medicaid expansion in narrowing delays by race and ethnicity has not been studied, to our knowledge. This was a population-based study using the National Cancer Database. Patients diagnosed with primary early-stage BC between 2007 and 2017 residing in states that underwent Medicaid expansion in January 2014 were included. Time to chemotherapy initiation and proportion of patients experiencing chemotherapy delays (>60 days) were evaluated using difference-in-difference and Cox proportional hazards models in preexpansion and postexpansion periods according to race and ethnicity. A total 100 643 patients were included (63 313 preexpansion and 37 330 postexpansion). After Medicaid expansion, the proportion of patients experiencing chemotherapy initiation delay decreased from 23.4% to 19.4%. The absolute decrease was 3.2, 5.3, 6.4, and 4.8 percentage points (ppt) for Black, Hispanic, White, and Other patients. Compared with White patients, statistically significant adjusted difference-in-differences were observed for Black (-2.1 ppt, 95% confidence interval [CI] = -3.7% to -0.5%) and Hispanic patients (-3.2 ppt, 95% CI = -5.6% to -0.9%). Statistically significant reductions in time to chemotherapy between expansion periods were observed among White patients (adjusted hazard ratio = .11, 95% CI = 1.09 to 1.12) and those belonging to racialized groups (adjusted hazard ratio = 1.14, 95% CI = 1.11 to 1.17). Among patients with early-stage BC, Medicaid expansion was associated with a reduction in racial disparities by decreasing the gap in the proportion of Black and Hispanic patients experiencing delays in adjuvant chemotherapy initiation.

Impact of Medicaid Expansion on Breast Cancer Diagnosis and Treatment in Southern States.

Medicaid expansion impacted patients when assessed at a national level. However, of the 32 states that expanded Medicaid, only three were Southern states. Whether results apply to Southern states that share similar geopolitical perspectives remains elusive. We aimed to assess the impact of Medicaid expansion on breast cancer diagnosis and treatment in 8 Southern states in the US. We identified uninsured or Medicaid patients (age 40 to 64 years) diagnosed with invasive breast cancer from 2011 to 2018 in Southern states from the North American Association of Central Cancer Registries-Cancer in North America Research Dataset. Medicaid-expanded states ([MES], Louisiana, Kentucky, Arkansas) were compared with non-MES ([NMES], Tennessee, Alabama, Mississippi, Texas, Oklahoma) using multivariate logistic regression and differences-in-differences analyses during pre- and postexpansion periods; p < 0.05 was considered statistically significant. Among 21,974 patients, patients in MES had increased odds of Medicaid insurance by 43% (odds ratio 1.43, p < 0.01) and decreased odds of distant-stage disease by 7% (odds ratio 0.93, p = 0.03). After Medicaid expansion, Medicaid patients increased by 10.6% in MES (Arkansas, Kentucky), in contrast to a 1.3% decrease in NMES (differences-in-differences 11.9%, p < 0. 0001, adjusting for age, race/ethnicity, rural-urban status, and poverty status). MES (Arkansas, Kentucky) had 2.3% fewer patients diagnosed with distant-stage disease compared with a 0.5% increase in NMES (differences-in-differences 2.8%, p = 0.01, after adjustment). Patients diagnosed in MES had higher odds of receiving treatment (odds ratio 2.27, p = 0.03). Unlike NMES, MES experienced increased Medicaid insured, increased treatment, and decreased distant-stage disease at diagnosis. Medicaid expansion in the South leads to earlier and more comprehensive treatment of breast cancer.

Abstract A061: Receipt of standard treatment by breast cancer patients on Medicaid, pre- and post-expansion

Abstract Background: Medicaid expansion in Ohio went into effect in 2014. While prior studies have shown earlier breast cancer stages at diagnosis post-expansion, its impact relative to receipt of standard treatment remains understudied. Here, we examined changes in stage-appropriate standard treatment by women with invasive incident breast cancer pre- and post-expansion, and by their timing of enrollment in Medicaid relative to cancer diagnosis – a key marker of inadequate access to care. Methods: We used 2011-2017 Ohio Cancer Incidence Surveillance System (OCISS) data linked with Medicaid enrollment and claims files. Our study population included women 18-65 years of age diagnosed with local- or regional-stage cancer (n=1,053 and n=2,264 women in the pre- and post-expansion periods, respectively). We identified women as Previously Enrolled if they enrolled in Medicaid at least 3 months prior to cancer diagnosis and remained continuously enrolled for 4 months post-diagnosis, and as Newly Enrolled if they enrolled in Medicaid in the 3 months before or after cancer diagnosis. We used the OCISS for sociodemographic and treatment data. We defined standard treatment as the receipt of mastectomy, or lumpectomy and radiation in all women. In those with regional-stage cancer, we required standard treatment to also include chemotherapy; and for those with positive hormonal status, we required hormonal therapy. From claims data, we identified comorbid conditions, grouped as none, physical conditions only, mental conditions only, and physical and mental conditions, with or without substance abuse. In addition to descriptive analysis, we conducted multivariable logistic regression analysis to evaluate the independent association between Medicaid expansion and receipt of standard treatment, after adjusting for patient demographics, tumor characteristics, and comorbid conditions. Results: The median age was 50.6 years and 51.8 years in the pre- and post-expansion periods. The percent of Newly Enrolled women relative to the total decreased from 24.8% to 18.9%. Women in this group were healthier than those in the Previously Enrolled group, as evidenced by the higher percent of women with no comorbid conditions (43.3% and 42.4% vs. 21.7% and 22.5%, Pre- and Post-expansion, respectively). From Pre- to Post-Expansion, receipt of standard treatment increased from 52.3% to 58.8% and from 58.6% to 61.6% among the Previously and Newly Enrolled, respectively. Results from the multivariable logistic regression analysis showed that compared to women diagnosed in the pre-expansion period, those diagnosed in the post-expansion period had 10% higher odds to receive standard treatment, after adjusting for patient covariates. Conversely, the timing of enrollment in Medicaid relative to cancer diagnosis was not associated with our outcome of interest. Conclusion: Medicaid expansion in Ohio was associated with improvements in receipt of stage-appropriate standard treatment for breast cancer. Future studies should elucidate the mechanisms at play. Citation Format: Siran M. Koroukian, Weichuan Dong, Kirsten Eom, Uriel M. Kim, Johnie Rose, Jeffrey Albert, Cynthia Owusu, Kristine Zanotti, Gregory S. Cooper, Jennifer Tsui. Receipt of standard treatment by breast cancer patients on Medicaid, pre- and post-expansion [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A061.

The Study of Phisical Changes in Bireuen Pendopo (Case Study: Pre-Independence, Independence And After Area Expansion)

Bireuen Regency is an area that has historical buildings from the Dutch colonial era, one of which is the Bireuen Pendopo. It is a cultural heritage building that is more than 70 years old based on the photo archive of Ir. Sukarno with the Bireuen fighter in 1948 and was certified as "The President Sukarno Heritage List". The building has undergone changes, seen from the period of pre-independence (1934–1944), the period of independence (1945–1999), and the period after the area expansion (1999–2021). Pendopo is a cultural heritage building. A study of its physical changes is urgently needed so that the original shape does not change and the material is not entirely replaced. The purpose of this study is to identify the physical changes in the Bireun Pendopo building. The research method used is descriptive qualitative. The physical elements are categorized into minor transformation, major transformation, and full transformation. The study's results found that the Bireun Pendopo building in the pre-independence period (1934-1944) did not have any changes in its physical form. While during the independence period (1945-1998), it underwent a minor physical transformation. In the period after the expansion of Bireun Regency (1999-2020), it underwent a minor physical transformation, a major transformation, and a full transformation. The results of the study that identified the physical changes of the Bireun Pendopo based on three periods showed that most of the changes were carried out in the post-expansion period with major and full transformation categories.

The Association Between Medicaid Expansion and Diabetic Ketoacidosis Hospitalizations.

Background and objective Diabetic ketoacidosis (DKA) is a potentially fatal complication of uncontrolled diabetes and remains a significant source of morbidity and mortality even though it is considered preventable. Diabetes is a chronic illness that requires constant monitoring and regular check-ups. Delaying or foregoing necessary diabetes care due to a lack of health insurance can result in severe complications. The Affordable Care Act (ACA) Medicaid expansion is intended to increase access to healthcare and improve health outcomes. This study aimed to examine the relationship between the ACA Medicaid expansion and hospitalizations with DKA. Methods This retrospective cross-sectional study used discharge records from 2010 to 2017 for hospitals in Texarkana, located on the border of Texas and Arkansas. The study employed a difference-in-differences method. Patients from Arkansas, which expanded Medicaid in 2014, constituted the treatment group, while those from Texas, which did not adopt the expansion, were the control group. A triple difference methodology was used to compare the impact of the expansion on patients with different socioeconomic backgrounds. The main outcome measure was DKA per 1000 discharges. Results A total of 89,184 inpatient discharges from Texarkana hospitals were analyzed; 43,286 patients were from Arkansas (48.54%) and 45,898 (51.46%) were from Texas. Even though DKA cases increased from pre-expansion (2010-2013) to post-expansion (2014-2017) period among patients from Arkansas (by a mean of 4.33) and Texas (by a mean of 8.28), the increase was milder among Arkansas patients with an adjusted decrease of 4.17 per 1000 discharges (95% CI: -5.04 to -3.31; p<0.001), implying a 42% lower risk of hospitalizations with DKA compared to the baseline averages. The triple difference analysis suggested that the decrease in incidences was more pronounced for patients from low-income areas with an adjusted decrease of 13.47 per 1000 discharges (95% CI: -22.45 to -4.49; p=0.003). Conclusions Based on our findings, Medicaid expansion decreases hospitalizations with DKA, presumably due to better monitoring and care of diabetes made possible by increasing access to healthcare among individuals with low incomes.

Cancer Mortality and the 2014 Medicaid Expansions under the Affordable Care Act

<h3>Purpose/Objective(s)</h3> Prior data have linked Medicaid expansions under the Affordable Care Act with improved insurance coverage among patients with cancer, earlier stages at diagnosis, and prolonged survival. Decreased cancer mortality rates were observed in connection with the limited early Medicaid expansions in 2010-2011, but changes associated with the more comprehensive and more recent Medicaid expansions starting in 2014 are not clear. We sought to test our hypothesis that Medicaid expansion was associated with decreased cancer mortality rates. <h3>Materials/Methods</h3> Data for cancer deaths among 20–64-year-old individuals from 2004-2018 were obtained from the National Center for Health Statistics. We obtained annual state-level cancer mortality rates covering all 50 U.S. states for deaths for all cancers combined and for deaths due to breast, cervical, colorectal, liver, lung, pancreatic, and prostate cancers, stratified by age group. State-level demographic data summarizing, age, employment, education, poverty, race/ethnicity, insurance, smoking, and obesity were also obtained and linked with the mortality data. We implemented a difference-in-differences analysis utilizing generalized estimating equations with state-level clustering to compare changes in mortality rates after 2014 between Medicaid expansion and non-expansion states. Models were adjusted for age, year, early (2010-2011) Medicaid expansion effects, and the aforementioned state-level demographic covariates. The common or parallel trends assumption was evaluated by examining for differential temporal trends in mortality rates between state groups and was satisfied for all analyses. Sensitivity analyses with interrupted time series analyses comparing trends in state groups were performed. <h3>Results</h3> Mortality rates for all cancers combined decreased from 92.2 to 85.5 per 100,000 in Medicaid expansion states compared to 98.4 to 93.5 per 100,000 in non-expansion states after 2014. In adjusted difference-in-differences analyses for all cancers combined, cancer mortality rates decreased after Medicaid expansion in expansion relative to non-expansion states (OR: 0.982, 95% CI = 0.965-0.999, p=.038), translating to 5174 cancer deaths that were averted in Medicaid expansion states in the post-expansion period. Expansion-associated reductions in mortality were also observed for breast (OR: 0.970, 95% CI = 0.947-0.993, p = 0.012), liver (OR: 0.939, 95% CI = 0.894-0.986, p = 0.011), and pancreatic cancers (OR: 0.968, 95% CI = 0.942-0.995, p = 0.019). Sensitivity analyses yielded similar results. <h3>Conclusion</h3> These data are the first to show statistically significant associations between state Medicaid expansions after 2014 and decreased overall cancer mortality rates. We observed expansion-associated reductions for all cancers combined and for breast, liver, and pancreatic cancers. Further advocacy efforts focusing on the 12 states that have not yet adopted Medicaid expansion may further reduce cancer mortality.

The Self-Sustainability of Federally Qualified Health Centers: Examining the Impact of Medicaid Expansion.

States' decisions to expand Medicaid eligibility would make most low-income uninsured people eligible for Medicaid, while also increasing the financial viability of Federally Qualified Health Centers (FQHCs) by reducing their grant to total revenue ratios. We extracted a national sample of 729 FQHCs for the period 2009 to 2018. The dependent variable was grant to revenue ratio and the independent variable was the states' Medicaid expansion status. FQHCs operating in Medicaid expansion states had lower grant ratios during the postexpansion period. As past decades' funding volatilities have shown, overreliance on one revenue source may increase financial risk. Medicaid expansion can support FQHCs by improving their long-term financial sustainability.

Palliative Therapies in Metastatic Pancreatic Cancer: Does Medicaid Expansion Make a Difference?

The aim of this study was to evaluate the impact of medicaid expansion (ME) on receipt of palliative therapies in metastatic pancreatic cancer patients. A difference-in-differences (DID) approach was used to analyze patients with metastatic pancreatic cancer identified from the National Cancer Database diagnosed during two time periods: pre-expansion (2010-2012) and post-expansion (2014-2016). Patients diagnosed while residing in ME states were compared with those in non-ME states. Multivariable logistic regression was used to identify predictors of receipt of palliative therapies. Of 87,738 patients overall, 7483(18.1%) received palliative therapies in the pre-expansion, while 10,211(21.5%) received palliative therapies in the post-expansion period. In the pre-expansion period, treatment at a high-volume facility (HVF) (odds ratio [OR] 1.10, 95% confidence interval [CI] 1.02-1.18) and non-west geographic location were predictive of increased palliative therapies. In the post-expansion period, treatment at an HVF (OR 1.09, 95% CI 1.02-1.16), geographic location, and living in an ME state at the time of diagnosis (OR 1.14, 95% CI 1.06-1.22) were predictive of increased palliative therapies. Older age, highest quartile median income (zip-code based), and treatment at a nonacademic facility were independently associated with decreased palliative therapies in both periods. DID analysis demonstrated that patients with metastatic pancreatic cancer living in ME states had increased receipt of palliative therapies relative to those in non-ME states (DID = 2.68, p < 0.001). The overall utilization of palliative therapies in metastatic pancreatic cancer is low. Multiple sociodemographic disparities exist in the receipt of palliative therapies. ME is associated with increased receipt of palliative therapies in patients with metastatic pancreatic cancer.

Improved depression screening and treatment among low-income pregnant and postpartum women following Medicaid expansion in the U.S.

This study examined the effect of Medicaid expansion in Oregon under the Affordable Care Act on depression screening and treatment among pregnant and postpartum women who gave Medicaid-financed births. Oregon birth certificates were linked to Medicaid enrollment and claims records for 2011-2016. The sample included a policy group of 1,368 women (n = 2,831) who gave births covered by pregnancy-only Medicaid in the pre-expansion period (before 2014) and full-scope Medicaid in the post-expansion period, and the comparison group of 2,229 women (n = 4,580) who gave births covered by full-scope Medicaid in both pre- and post-expansion periods. Outcomes included indicators for depression screening, psychotherapy, pharmacotherapy, and combined psychotherapy-pharmacotherapy, separately for the first, second, and third trimesters, and 2 and 6 months postpartum. This study utilized a difference-in-differences approach that compared pre-post change in an outcome for the policy group to a counterfactual pre-post change from the comparison group. Medicaid expansion led to a 3.64%-point increase in the rate of depression screening 6 months postpartum, 3.28%-point increase in the rate of psychotherapy 6 months postpartum, and 2.3 and 1%-point increases in the rates of pharmacotherapy and combined treatment in the first trimester, respectively. The relationships were driven by disproportionate gains among non-Hispanic whites and urban residents. Expanding Medicaid eligibility may improve depression screening and treatment among low-income women early in pregnancy and/or beyond the usual two-month postpartum period. However, it does not necessarily reduce racial/ethnic and regional gaps in depression screening and treatment.

Medicaid expansion, managed care plan composition, and enrollee experience.

To examine changes in plan composition and enrollee experience associated with Medicaid expansion among Medicaid managed care organization (MCO) enrollees. Using 2012-2018 Adult Medicaid Consumer Assessment of Healthcare Providers and Systems surveys, we estimated changes in MCO enrollee characteristics and 4 outcomes: having access to needed care, having a personal doctor, having timely access to a checkup, and having timely access to specialty care. We estimated multivariable linear probability models comparing pre- vs postexpansion changes in expansion vs nonexpansion states. The postexpansion period was modeled as an event-study regression to account for changes over time. The coefficient of interest was a Medicaid expansion-by-year term. Medicaid expansion was associated with statistically significant decreases in the proportion of female enrollees (-8.4 percentage points [PP]; P < .01) and increases in the proportion of enrollees who were aged 55 to 64 years (6.8 PP; P < .01) and were non-Hispanic White (4.4 PP; P < .01). Relative to enrollees in nonexpansion states, MCO enrollees in expansion states were significantly less likely to report access to a personal doctor (-1.6 PP; 95% CI, -3.0 to -0.1 PP) and less likely to report timely access to specialty care (-2.1 PP; 95% CI, -3.4 to -0.8 PP; P < .01) in the first year after expansion. Differences were not statistically significant by the second year post expansion. There were not significant changes in the other 2 outcomes. State policy makers may need to account for the role that Medicaid expansion may have in changing Medicaid MCO enrollee composition to prevent unfair penalization on performance metrics.

Utilization of telemedicine among patients newly diagnosed with cancer.

1595 Background: The use of telemedicine among cancer patients remains limited. Because of the COVID-19 pandemic, CMS expansion of telehealth with 1135 waiver was enacted in March 2020, broadening the opportunities to provide patient care using telemedicine. This study examined the impact of the CMS expansion on the use of telemedicine among cancer patients. Methods: We identified newly diagnosed patients with 5 common cancers (breast, prostate, lung, colorectal, and lymphoma) between 3/2019 and 12/2020 from Optum’s de-identified Clinformatics Data Mart Database. Patients who had 6 months of full enrollment (3 months before and 3 months after the first [index] cancer diagnosis date), had cancer claims on 3 separate dates within 3 months of the index date for the specific cancer diagnosis, and no prior history of cancer were included. We defined telemedicine use as patients who had a telemedicine procedure code within 1 month of their index diagnosis and had the cancer diagnosis on the telemedicine claim. We conducted an interrupted time series analysis to examine the impact of CMS expansion on telemedicine use. A multivariable logistic regression model was used to identify factors associated with telemedicine use during the post-expansion period. Results: Of 96,632 patients included, the average crude rate of telemedicine use was 0.12% before and 14.2% after the expansion in March 2020 (see Table). There was a significant impact of expansion on telemedicine use (21% increase; p&lt;0.001). The peak rate (adjusted) was 28% in April 2020, decreasing and plateauing in July/August 2020, with rates staying in the range of 10-12% between August and December 2020. During the post-expansion period, lymphoma, prostate, and lung cancer patients (adjusted rates: 14.6%, 15.7%, and 15.9%, respectively) were more likely to use telemedicine compared to patients who had breast (12.7%) or colorectal (12.3%) cancer. Patients who were older (adjusted rates: ≥65 years, 13.8%; 50-64, 14.2%; 20-49, 18.6%), Black (12.4% vs 14.4% for White, 15.5% for Hispanic and 16.6% for Asian), resided in East South Central census division (8.4% vs 23.5% in New England) and had Medicare (12.2% vs 20.3% for commercial insurance) were less likely to use telemedicine (all p&lt;.001). Conclusions: After the CMS telehealth expansion, the use of telemedicine among newly diagnosed cancer patients increased significantly. Telemedicine use varied by patient age, geographic location, race/ethnicity, and payer. Further research is needed to understand the pattern of telemedicine use.[Table: see text]

Affordable Care Act Medicaid expansion and access to primary-care based smoking cessation assistance among cancer survivors: an observational cohort study

BackgroundSmoking among cancer survivors can increase the risk of cancer reoccurrence, reduce treatment effectiveness and decrease quality of life. Cancer survivors without health insurance have higher rates of smoking and decreased probability of quitting smoking than cancer survivors with health insurance. This study examines the associations of the Affordable Care Act (ACA) Medicaid insurance expansion with smoking cessation assistance and quitting smoking among cancer survivors seen in community health centers (CHCs).MethodsUsing electronic health record data from 337 primary care community health centers in 12 states that expanded Medicaid eligibility and 273 CHCs in 8 states that did not expand, we identified adult cancer survivors with a smoking status indicating current smoking within 6 months prior to ACA expansion in 2014 and ≥ 1 visit with smoking status assessed within 24-months post-expansion. Using an observational cohort propensity score weighted approach and logistic generalized estimating equation regression, we compared odds of quitting smoking, having a cessation medication ordered, and having ≥6 visits within the post-expansion period among cancer survivors in Medicaid expansion versus non-expansion states.ResultsCancer survivors in expansion states had higher odds of having a smoking cessation medication order (adjusted odds ratio [aOR] = 2.54, 95%CI = 1.61-4.03) and higher odds of having ≥6 office visits than those in non-expansion states (aOR = 1.82, 95%CI = 1.22-2.73). Odds of quitting smoking did not differ significantly between patients in Medicaid expansion versus non-expansion states.ConclusionsThe increased odds of having a smoking cessation medication order among cancer survivors seen in Medicaid expansion states compared with those seen in non-expansion states provides evidence of the importance of health insurance coverage in accessing evidence-based tobacco treatment within CHCs. Continued research is needed to understand why, despite increased odds of having a cessation medication prescribed, odds of quitting smoking were not significantly higher among cancer survivors in Medicaid expansion states compared to non-expansion states.

Association of Medicaid Expansion With Mortality Disparity by Race and Ethnicity Among Patients With De Novo Stage IV Breast Cancer

Patients who are uninsured and belong to racial and ethnic minority groups or have low socioeconomic status have suboptimal access to health care, likely affecting outcomes. The association of the Affordable Care Act's Medicaid expansion with survival among patients with metastatic breast cancer is unknown. To examine the association between Medicaid expansion and mortality disparity among patients with de novo stage IV breast cancer. Cross-sectional, population-based study of survival using Cox proportional hazards regression and difference-in-difference (DID) analysis of data from the National Cancer Database and patients diagnosed as having de novo stage IV breast cancer between January 1, 2010, and December 31, 2016, residing in states that underwent Medicaid expansion on January 1, 2014. The preexpansion period was January 1, 2010, to December 31, 2013; the postexpansion period was January 1, 2014, to December 31, 2016. Data were analyzed between September 4, 2020, and November 16, 2021. Comparison of survival improvement between patients of racial and ethnic minority groups and White patients in the preexpansion and postexpansion periods. Because of small numbers in the specific racial and ethnic minority groups, these patients were combined into 1 category for comparisons. Overall survival (OS) and 2-year mortality rate. Among 9322 patients included (mean [SD] age, 55 [7] years), 5077 were diagnosed in the preexpansion and 4245 in the postexpansion period. The racial and ethnic minority group comprised 2545 (27.3%), which included 500 (5.4%) Hispanic (any race), 1515 (16.3%) non-Hispanic Black, and 530 (5.7%) non-Hispanic other including 25 (0.3%) American Indian or Alaska Native, 357 (3.8%) Asian or Pacific Islander, and 148 (1.6%) unknown, and 6777 (72.7%) were in the White patient group. In the preexpansion period, White patients had increased OS compared with patients of racial and ethnic minority groups (adjusted hazard ratio [aHR], 1.22; 95% CI, 1.10-1.35); this difference was not observed in the postexpansion period (aHR, 0.96; 95% CI, 0.86-1.08). A reduction in 2-year mortality was observed between the preexpansion and postexpansion periods (32.2% vs 26.0%). The adjusted 2-year mortality decreased from 40.6% to 36.3% among White patients and from 45.6% to 35.8% among patients of racial and ethnic minority groups (adjusted DID, -5.5%; 95% CI, -9.5 to -1.6; P = .006). Among patients in the lowest income quartile (n = 1510), patients of racial and ethnic minority groups had an increased risk of death in the preexpansion period (aHR, 1.28; 95% CI, 1.01-1.61) but lower risk in the postexpansion period (aHR, 0.75; 95% CI, 0.59-0.95). In this subset of patients, those of racial and ethnic minority groups had a greater reduction in 2-year mortality compared with White patients (adjusted DID, -12.8%; 95% CI, -22.2 to -3.5; P = .007). In this cross-sectional study, survival differences observed between patients of racial and ethnic minority groups and White patients in the preexpansion period were no longer present in the postexpansion period. A greater reduction in 2-year mortality was observed among patients of racial and ethnic minority groups compared with White patients. These results suggest that policies aimed at improving equity and increasing access to health care may reduce racial and ethnic disparities in breast cancer outcomes.