Did Medicaid Expansion Impact Cancer Diagnosis Rates?

Medicaid expansion was associated with a decreased rate of uninsured patients as well as an increased rate of early-stage cancer diagnosis, according to data from a study on the Affordable Care Act (ACA) published in JAMA Network Open.

Investigators from the Perelman School of Medicine at the University of Pennsylvania conducted a cross-sectional study of 848,329 patients with breast, colon, and lung cancer to determine what effect changes to Medicaid had on insurance status, stage at diagnosis, and timely treatment. The study authors explained that the ACA expanded Medicaid eligibility and provided 20 million more US residents with healthcare coverage. While some studies suggest longer wait times as a result of Medicaid expansion, others demonstrate improved access to care, affordability, and better outcomes in some situations, the study authors said.

The investigators collected data between January 1, 2011, and December 31, 2016, with the January 1, 2014, line of demarcation noting the expansion of Medicaid programs. Patients with new diagnoses of invasive breast, colon, or lung cancers aged 40 to 64 years were included in the analysis. Time-to-treatment initiation (TTI) was divided into 2 groups: TTI within 30 and TTI within 90 days of diagnosis. The study authors noted that a short TTI is clinically beneficial in nonmetastatic breast cancer cases, while the optimal TTI for lung and colon cancers remains unclear.

New breast cancer diagnoses were observed in 58% of the patients, about half of whom resided in Medicaid expansion states, the investigators found. Those within the expansion states also were more likely to reside in wealthier, more metropolitan zip codes; have no comorbidities; and seek cancer at an academic center. They also were less likely to be uninsured or present with metastatic cancer, the investigators said.

Additionally, patients in expansion states were more likely to be diagnosed with early-stage cancers and less likely to be diagnosed with advanced-stage cancers throughout the study period, the investigators noted. In nonexpansion states, the percentages of early and advanced-stage diagnoses stayed relatively constant.

The investigators said that no impact was made on the rate of timely treatment. For both groups, the percentages treated within 30 and 90 days of diagnosis were greater in nonexpansion states but decreased over time throughout the study period. Thirty-day treatment rates declined in both expansion and nonexpansion state: from 52.7% to 48.0% (95% CI, −5.1 to −4.5 percentage points) and from 56.9% to 51.5% (95% CI, −5.6 to −5.1 percentage points), respectively, the investigators wrote. They said the results were similar when viewed through the lens of the 90-day treatment window.

“We found no association of Medicaid expansion with the timeliness of treatment initiation. For patients with cancer, insurance coverage has been shown to afford better access to effective cancer therapies, which could conceivably improve rates of timely treatment in expansion states. However, if a surge in insured patients with cancer overwhelmed an already strained oncology workforce, lengthened wait times and costly treatment delays could result, as have occurred outside oncology,” the study authors concluded.

They suggest initiation of research on how Medicaid expansion has affected treatment patterns and outcomes among patients with cancer.