Introduction
The expansion of Medicaid under the Affordable Care Act increased access to health
care for millions of low-income Americans. However, the longer-term impacts of the
policy on cancer outcomes remain unknown. This study examined the impact of Medicaid
expansion on early- and late-stage diagnosis for 4 common cancers (breast, cervical,
colorectal, and lung) using 4 full years of postpolicy data.
Methods
Patients aged 40–64 years diagnosed with breast, cervical, colorectal, or lung cancer
from 2010 to 2017 were identified using the National Cancer Database. Difference-in-difference
analyses compared changes in early-stage and late-stage diagnoses among expansion
states with those among nonexpansion states. Subgroup analyses explored potential
effect modification by insurance type. Data analysis was performed from June to October
2021.
Results
The proportion of early stage diagnosis of breast (difference in difference=1.58,
95% CI=0.89, 2.27), cervical (difference in difference=3.20; 95% CI=0.44, 5.95), colorectal
(difference in difference=1.98; 95% CI=1.18, 2.78), and lung (difference in difference=1.74;
95% CI=0.98, 2.50) cancers increased more in expansion states than in nonexpansion
states, whereas late-stage diagnosis of colorectal (difference in difference= −2.12;
95% CI= −2.98, −1.27) and lung (difference in difference= −1.87; 95% CI= −2.89, −0.84)
cancers decreased more in expansion states following implementation of the Affordable
Care Act. In subgroup analyses, difference-in-difference estimates for all sites and
stages (except late-stage cervical cancer) were significant and larger in magnitude
among Medicaid-insured than among privately insured patients.
Conclusions
Study results highlight the positive impacts of Medicaid expansion on earlier diagnosis
of several cancers for which screening and early detection exist, and subgroup analyses
revealed greater positive effects among Medicaid-insured patients most targeted by
the policy.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to American Journal of Preventive MedicineAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
REFERENCES
- Cancer statistics, 2021.CA Cancer J Clin. 2021; 71: 7-33https://doi.org/10.3322/caac.21654
- Cancer Prevention & Early Detection Facts & Figures 2019–2020.American Cancer Society, Atlanta2019
- Association of insurance with cancer care utilization and outcomes.CA Cancer J Clin. 2008; 58: 9-31https://doi.org/10.3322/CA.2007.0011
- Association of insurance status and ethnicity with cancer stage at diagnosis for 12 cancer sites: a retrospective analysis.Lancet Oncol. 2008; 9: 222-231https://doi.org/10.1016/S1470-2045(08)70032-9
- Evaluating Medicaid expansion benefits for patients with cancer: National Cancer Database analysis and systematic review.J Cancer Policy. 2021; 29100292https://doi.org/10.1016/j.jcpo.2021.100292
- Key provisions of the Patient Protection and Affordable Care Act (ACA): a systematic review and presentation of early research findings.Health Serv Res. 2016; 51: 1735-1771https://doi.org/10.1111/1475-6773.12511
- Comparison of insurance status and diagnosis stage among patients with newly diagnosed cancer before vs after implementation of the Patient Protection and Affordable Care Act.JAMA Oncol. 2018; 4: 1713-1720https://doi.org/10.1001/jamaoncol.2018.3467
- Changes in insurance coverage and stage at diagnosis among nonelderly patients with cancer after the Affordable Care Act.J Clin Oncol. 2017; 35: 3906-3915https://doi.org/10.1200/JCO.2017.73.7817
- Effect of Medicaid expansions of 2014 on overall and early-stage cancer diagnoses.Am J Public Health. 2018; 108: 216-218https://doi.org/10.2105/AJPH.2017.304166
- Early- and late-stage cancer diagnosis under 3 years of Medicaid expansion.Am J Prev Med. 2021; 60: 104-109https://doi.org/10.1016/j.amepre.2020.06.020
- The effect of Medicaid expansion among adults from low-income communities on stage at diagnosis in those with screening-amenable cancers.Cancer. 2020; 126: 4209-4219https://doi.org/10.1002/cncr.32895
- Association of Medicaid expansion under the Affordable Care Act with insurance status, cancer stage, and timely treatment among patients with breast, colon, and lung cancer.JAMA Netw Open. 2020; 3e1921653https://doi.org/10.1001/jamanetworkopen.2019.21653
- Association of Medicaid expansion under the Affordable Care Act with breast cancer stage at diagnosis.JAMA Surg. 2020; 155: 752-758https://doi.org/10.1001/jamasurg.2020.1495
- Evaluation of insurance coverage and cancer stage at diagnosis among low-income adults with renal cell carcinoma after passage of the Patient Protection and Affordable Care Act.JAMA Netw Open. 2021; 4e2116267https://doi.org/10.1001/jamanetworkopen.2021.16267
- Associations of early Medicaid expansion with insurance status and stage at diagnosis among cancer patients receiving radiation therapy.Pract Radiat Oncol. 2020; 10: e207-e218https://doi.org/10.1016/j.prro.2019.10.003
- Positive impact of the Patient Protection and Affordable Care Act Medicaid expansion on Louisiana women with breast cancer.Cancer. 2021; 127: 688-699https://doi.org/10.1002/cncr.33265
- Using the National Cancer Database for outcomes research: a review.JAMA Oncol. 2017; 3: 1722-1728https://doi.org/10.1001/jamaoncol.2016.6905
- Practical guide to surgical data sets: National Cancer Database (NCDB).JAMA Surg. 2018; 153: 850-851https://doi.org/10.1001/jamasurg.2018.0492
- Methods for evaluating changes in health care policy: the difference-in-differences approach.JAMA. 2014; 312: 2401-2402https://doi.org/10.1001/jama.2014.16153
- Mostly Harmless Econometrics.Princeton University Press, 2008https://doi.org/10.2307/j.ctvcm4j72
- Stata Statistical Software: Release 15.StataCorp LLC, College Station, TX2017
- Association of Medicaid expansion with cancer stage and disparities in newly diagnosed young adults.J Natl Cancer Inst. 2021; 113: 1723-1732https://doi.org/10.1093/jnci/djab105
- Changes in breast and colorectal cancer screening after Medicaid expansion under the Affordable Care Act.Am J Prev Med. 2019; 57: 3-12https://doi.org/10.1016/j.amepre.2019.02.015
- Increased cancer screening for low-income adults under the Affordable Care Act Medicaid expansion.Med Care. 2018; 56: 944-949https://doi.org/10.1097/MLR.0000000000000984
- Changes in receipt of cancer screening in Medicare beneficiaries following the Affordable Care Act.J Natl Cancer Inst. 2016; 108https://doi.org/10.1093/jnci/djv374
- Lung cancer screening utilization: a behavioral risk factor surveillance system analysis.Am J Prev Med. 2019; 57: 250-255https://doi.org/10.1016/j.amepre.2019.03.015
- Trends in lung cancer screening in the United States, 2016–2017.J Thorac Dis. 2019; 11: 873-881https://doi.org/10.21037/jtd.2019.01.105
- Use of CT and chest radiography for lung cancer screening before and after publication of screening guidelines: intended and unintended uptake.JAMA Intern Med. 2017; 177: 439-441https://doi.org/10.1001/jamainternmed.2016.9016
- New recommendation and coverage of low-dose computed tomography for lung cancer screening: uptake has increased but is still low.BMC Health Serv Res. 2018; 18: 525https://doi.org/10.1186/s12913-018-3338-9
- The National Breast and Cervical Cancer Early Detection Program: a comprehensive public health response to two major health issues for women.J Public Health Manag Pract. 1996; 2: 36-47https://doi.org/10.1097/00124784-199621000-00007
- The Colorectal Cancer Control Program: partnering to increase population level screening.Gastrointest Endosc. 2011; 73: 429-434https://doi.org/10.1016/j.gie.2010.12.027
- Screening for cervical cancer: US Preventive Services Task Force recommendation statement.JAMA. 2018; 320: 674-686https://doi.org/10.1001/jama.2018.10897
Article Info
Publication History
Published online: July 21, 2022
Publication stage
In Press Journal Pre-ProofIdentification
Copyright
© 2022 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.
