CHICAGO (November 23, 2020): The Affordable Care Act's Medicaid expansion for low-income people appears to lead to earlier diagnosis of colon cancer, enhanced access to care, and improved surgical care for patients with this common cancer, researchers report in a new study. The study is published as an "article in press" on the Journal of the American College of Surgeons website in advance of print.
In states that expanded Medicaid health insurance coverage in 2014, the study authors reported an increase of early-stage colon cancer diagnoses compared with states that did not implement Medicaid expansion. More surgical patients from states with Medicaid expansion had minimally invasive surgical procedures, and fewer patients underwent urgent operations than in states not implementing expansion, said lead author Richard S. Hoehn, MD, surgical oncology fellow with the University of Pittsburgh Medical Center (UPMC) department of surgery at UPMC Hillman Cancer Center, Pittsburgh, Pa.
"A paucity of studies looks at how Medicaid expansion affects cancer treatment and outcomes, as our study did," Dr. Hoehn said. "Our study also differed from others in that we analyzed data only from people who were most likely affected by Medicaid expansion: those aged 40 to 64 who had Medicaid or no health insurance."
Medicaid expansion, which took effect January 1, 2014, extended this public health insurance coverage to more low-income people.1 Initially, 19 states did not implement Medicaid expansion, but to date, all but 12 states have adopted the expansion.1
Access to health care may be especially important for colon cancer, the authors wrote in their article. Colon and rectal cancer is the fourth most common cancer in the United States and is increasing among adults younger than age 652--those not yet eligible for Medicare, the country's public health insurance for seniors. Despite the availability of colonoscopy to screen for colorectal cancer, the American Cancer Society reports that one in three Americans who should receive this screening do not, for reasons including inadequate health insurance.3
The researchers used data on invasive colon cancer collected in the National Cancer Database (NCDB), the largest cancer registry of its kind. Cosponsored by the American College of Surgeons and the American Cancer Society, the NCDB includes information on more than 70 percent of newly diagnosed cancer cases in the U.S.
Dr. Hoehn and his colleagues compared colon cancer data for 4,438 patients residing in 19 states that implemented expansion in January 2014 ("expansion states") with data for 6,017 patients in 19 "nonexpansion" states at that time. To estimate the relative effect of the expansion policy, they selected the years 2011-2012 to assess data before expansion and 2015-2016 for post-expansion data.
In statistical analyses between these periods, the investigators observed no significant differences between Medicaid expansion and nonexpansion states for postoperative outcomes such as hospital length of stay, readmission rates, and deaths. However, patients with colon cancer stages I to III did have differences in timeliness of care based on their state expansion category. In nonexpansion states, the days to treatment (primarily surgical) increased and the proportion of patients treated in less than 30 days decreased. Dr. Hoehn said they did not observe these delays in care in expansion states.
Other key differences in the 2015-2016 period were as follows:
- A larger number of patients in expansion states received treatment at integrated network cancer programs accredited by the Commission on Cancer of the American College of Surgeons. Research evidence for other cancer types suggests these programs offer better overall survival rates.4,5
- Patients traveled farther for care in expansion states, suggesting that patients who lived greater distances from hospitals could now obtain care because of coverage, Dr. Hoehn noted.
- Patients in expansion states who had end-stage colon cancer were more likely to receive palliative care services, which aim to improve quality of life.
- Among patients who underwent cancer operations, more in expansion states had minimally invasive surgery and nonurgent operations. Dr. Hoehn said both changes may be due to earlier diagnosis in these states.
The reasons why patients in expansion states had more stage I diagnoses after expansion than before are unclear from the data but may point to better access to care, said senior investigator Samer T. Tohme, MD, surgical oncologist at UPMC Hillman Cancer Center and assistant professor of surgery at the University of Pittsburgh School of Medicine. He said their findings suggest that Medicaid expansion has enabled more previously uninsured people to see a primary care physician and get screened for colon cancer.
"Studies show that patients who are diagnosed with cancer at an earlier stage are more likely to have better treatment options, improved quality of care, and longer survival," Dr. Tohme said.
Their study, however, did not track survival rates or other long-term results.
Dr. Hoehn said it is important to study the impact of expanded health insurance coverage.
"Studies like ours are building an increasing body of work that suggests the Affordable Care Act and Medicaid expansion are improving health care access and treatment for cancer patients," he said.
Other study authors are Caroline J. Rieser, MD; Heather Phelos, MPH; Ibrahim Nassour, MD, MSCS; Alessandro Paniccia, MD; and Amer H. Zureikat, MD, FACS, of the UPMC Department of Surgery and Lindsay M. Sabik, PhD, from the University of Pittsburgh Graduate School of Public Health.
"FACS" designates that a surgeon is a Fellow of the American College of Surgeons.
The University of Pittsburgh department of surgery funded this work. The authors report no disclosures.
Citation: The Association of Medicaid expansion with the Diagnosis and Management of Colon Cancer. Journal of the American College of Surgeons. DOI: https://doi.org/10.1016/j.jamcollsurg.2020.10.021.
1 Kaiser Family Foundation. Status of state Medicaid expansion decisions: interactive map. Updated November 2, 2020. Accessed November 12, 2020. Available at: https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/.
2 National Cancer Institute, Surveillance, Epidemiology, and End Results (SEER) Program. Cancer stat facts: colorectal cancer. Accessed November 13, 2020. Available at: https://seer.cancer.gov/statfacts/html/colorect.html.
3 American Cancer Society. Colorectal cancer early detection, diagnosis, and staging. Accessed November 12, 2020. Available at: https://www.cancer.org/content/dam/CRC/PDF/Public/8606.00.pdf
4 Thiels CA, Hanson KT, Habermann EB, Boughey JC, Grotz TE. Integrated cancer networks improve compliance with national guidelines and outcomes for resectable gastric cancer. Cancer. 2020;126(6):1283-1294.
5 Carey RM, Fathy R, Shah RR, et al. Association of type of treatment facility with overall survival after a diagnosis of head and neck cancer. JAMA Netw Open. 2020;3(1):e1919697.
About the American College of Surgeons
The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 82,000 members and is the largest organization of surgeons in the world. For more information, visit http://www.facs.org.
Journal of the American College of Surgeons