Advertisement

Impacts of Medicaid Expansion on Stage at Cancer Diagnosis by Patient Insurance Type

      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 access
      One-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 Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      REFERENCES

        • Siegel RL
        • Miller KD
        • Fuchs HE
        • Jemal A.
        Cancer statistics, 2021.
        CA Cancer J Clin. 2021; 71: 7-33https://doi.org/10.3322/caac.21654
        • American Cancer Society
        Cancer Prevention & Early Detection Facts & Figures 2019–2020.
        American Cancer Society, Atlanta2019
        • Ward E
        • Halpern M
        • Schrag N
        • et al.
        Association of insurance with cancer care utilization and outcomes.
        CA Cancer J Clin. 2008; 58: 9-31https://doi.org/10.3322/CA.2007.0011
        • Halpern MT
        • Ward EM
        • Pavluck AL
        • Schrag NM
        • Bian J
        • Chen AY.
        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
        • Nathan NH
        • Bakhsheshian J
        • Ding L
        • Mack WJ
        • Attenello FJ.
        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
        • French MT
        • Homer J
        • Gumus G
        • Hickling L.
        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
        • Han X
        • Yabroff KR
        • Ward E
        • Brawley OW
        • Jemal A.
        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
        • Jemal A
        • Lin CC
        • Davidoff AJ
        • Han X.
        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
        • Soni A
        • Simon K
        • Cawley J
        • Sabik L.
        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
        • Lin L
        • Soni A
        • Sabik LM
        • Drake C.
        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
        • Kim U
        • Koroukian S
        • Statler A
        • Rose J.
        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
        • Takvorian SU
        • Oganisian A
        • Mamtani R
        • et al.
        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
        • Le Blanc JM
        • Heller DR
        • Friedrich A
        • Lannin DR
        • Park TS
        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
        • Javier-DesLoges JF
        • Yuan J
        • Soliman S
        • et al.
        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
        • Barnes JM
        • Srivastava AJ
        • Gabani P
        • Perkins SM.
        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
        • Chu QD
        • Li T
        • Hsieh MC
        • et al.
        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
        • Boffa DJ
        • Rosen JE
        • Mallin K
        • et al.
        Using the National Cancer Database for outcomes research: a review.
        JAMA Oncol. 2017; 3: 1722-1728https://doi.org/10.1001/jamaoncol.2016.6905
        • Merkow RP
        • Rademaker AW
        • Bilimoria KY.
        Practical guide to surgical data sets: National Cancer Database (NCDB).
        JAMA Surg. 2018; 153: 850-851https://doi.org/10.1001/jamasurg.2018.0492
        • Dimick JB
        • Ryan AM.
        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
        • Angrist JD
        • Pischke J-S.
        Mostly Harmless Econometrics.
        Princeton University Press, 2008https://doi.org/10.2307/j.ctvcm4j72
        • StataCorp
        Stata Statistical Software: Release 15.
        StataCorp LLC, College Station, TX2017
        • Ji X
        • Castellino SM
        • Mertens AC
        • et al.
        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
        • Fedewa SA
        • Yabroff KR
        • Smith RA
        • Goding Sauer AG
        • Han X
        • Jemal A
        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
        • Hendryx M
        • Luo J.
        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
        • Cooper GS
        • Kou TD
        • Schluchter MD
        • Dor A
        • Koroukian SM.
        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
        • Zahnd WE
        • Eberth JM.
        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
        • Okereke IC
        • Nishi S
        • Zhou J
        • Goodwin JS.
        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
        • Huo J
        • Shen C
        • Volk RJ
        • Shih Y-CT.
        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
        • Li J
        • Chung S
        • Wei EK
        • Luft HS.
        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
        • Henson RM
        • Wyatt SW
        • Lee NC.
        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
        • Joseph DA
        • DeGroff AS
        • Hayes NS
        • Wong FL
        • Plescia M.
        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
        • Curry SJ
        • Krist AH
        • et al.
        • US Preventive Services Task Force
        Screening for cervical cancer: US Preventive Services Task Force recommendation statement.
        JAMA. 2018; 320: 674-686https://doi.org/10.1001/jama.2018.10897