Public Release: 

Medicaid expansion led to increase in screening for colorectal cancer patients in Kentucky

American College of Surgeons

CHICAGO (February 22, 2019): Kentucky is one of the poorest states in the U.S.1 However, the state has been one of the most successful in reducing its uninsured rate, which happened in part through the Affordable Care Act's Medicaid expansion that took effect on January 1, 2014.2 In the past, Kentucky has reported low rates of colorectal cancer (CRC) screening and has ranked among the highest states for incidence and mortality for the disease. One research team evaluated the impact of Medicaid expansion on the rates of CRC screening, incidence, and survival among the state's low-income population. The researchers found that the number of Medicaid patients who received screening after the expansion was more than triple the number of patients who were screened before the expansion. Additionally, CRC patients relying on Medicaid exhibited improved survival after the expansion compared to before it was implemented. The findings were published as an "article in press" on the website of the Journal of the American College of Surgeons ahead of print.

The Affordable Care Act's Medicaid expansion provided insurance coverage to those at 138 percent of the federal poverty level. In Kentucky, the expansion meant that an additional 634,807 low-income people gained access to Medicaid.2 Many people in this population have a low level of education and don't have easy access to a physician, especially the more rural Appalachian population in eastern Kentucky, said the lead study author, Avinash Bhakta, MD, a colorectal surgeon at the University of Kentucky Markey Cancer Center, Lexington. Dr. Bhakta said he began treating more and more patients from Appalachian Kentucky, and he wanted to look further into how the Affordable Care Act could be related to the increase of patients he was treating.

"For me, it was bit of a wake-up call living in our society and seeing the population that I treat in Kentucky, particularly in Appalachia," Dr. Bhakta said. "Many of these patients paved their own roads to come see me in Lexington. We didn't really see much study on the effect of the Affordable Care Act Medicaid expansion, and with our population having the leading incidence and mortality rate of CRC in the country, we felt that it was an ideal population to study this potential impact."

To conduct the study, the researchers obtained data on Kentucky's CRC screening, incidence, and outcomes from the Kentucky Hospital Discharge Database and the Kentucky Cancer Registry. The study population included 930,176 patients older than 20 years who underwent CRC screening from January 1, 2011 to December 31, 2016. A total of 408,500 patients were screened before Medicaid expansion (January 1, 2011 to December 31, 2013) and 521,676 patients were screened after Medicaid expansion (January 1, 2014 to December 31, 2016). The researchers obtained measures including demographics, insurance coverage based on information at the time of diagnosis, socioeconomics (percentage below poverty status and high school education at the county level), and clinical information (tumor grade, stage at diagnosis, and survival).

One of the most significant results from this study, Dr. Bhakta said, was that patients with Medicaid demonstrated the highest increase in CRC screening. A total of 69,328 Medicaid patients received screening after the expansion compared with 20,980 patients who were screened before the expansion--an increase of 230 percent. Additionally, 43.7 percent more Appalachian patients received screening after the expansion. When looking specifically at Medicaid patients, the researchers wrote, individuals in the 51-65 age group had the highest improvement in screening with an increase of 292.5 percent. Medicaid coverage of Appalachian patients increased by 199 percent.

From January 1, 2011 to December 31, 2016, 11,441 Kentucky patients were diagnosed with CRC. When separated by insurance, the proportion of Medicaid patients diagnosed with CRC increased by 132.4 percent after Medicaid expansion, the authors wrote. Dr. Bhakta said that increase was "a difficult number for me to swallow," because with increased screening, there should be a drop in incidence. However, Dr. Bhakta noted that this research is still young. If the researchers follow the data for another five or 10 years, he anticipates seeing a drop in incidence.

The researchers also reported that after expansion, Medicaid patients exhibited improved survival compared with patients prior to expansion. The survival differences after expansion were evident in Medicaid patients after the first year and increased each year thereafter. Appalachian patients with Medicaid coverage had significantly improved survival after expansion compared with before expansion, the researchers wrote.

"We saw that month to month post expansion, there was an improvement in survival from the pre-expansion era in our Medicaid population," Dr. Bhakta said. "We were able to follow many of these patients for up to eight years, and we are continuing to keep track of them and their recurrences and overall survival."

The most important takeaway from this study, Dr. Bhakta said, is that as more people get screened for CRC, more people will have improved survival.

"We know that with increased screening, we're able to get increased detection of earlier polyps," he said. "The Medicaid expansion allowed us to get access to a lot of near-poor patients that would have otherwise not been able to get screened."

Now that the researchers have identified the problem, they will continue to gather data and find solutions for the state's high mortality rate from CRC. "After these individuals are screened and diagnosed with colorectal cancer, are we not navigating them appropriately to surgery? After their operations, are the patients with advanced tumors not getting chemotherapy in a timely fashion?" Dr. Bhakta asked. "Finally, is this patient population that we treat at UK Markey Cancer Center resistant to traditional chemotherapeutic agents? These questions and barriers are important for us to investigate in order to continue our fight against colorectal cancer," Dr. Bhakta said.

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Dr. Bhakta's coauthors were Tong Gan, MD; Heather F. Sinner, MD; Samuel C. Walling, MD; Quan Chen, DrPH; Bin Huang, DrPH; Tom C. Tucker, PhD; Jitesh A. Patel, MD, FACS; and B. Mark Evers, MD, FACS, all of the University of Kentucky.

Study results were presented at the 130th Annual Meeting of the Southern Surgical Association, December 2018.

Data collection activities of the Kentucky Cancer Registry are supported by the National Cancer Institute Surveillance Epidemiology and End Results Program (NCI HHSN26100001), and the Center for Disease Control and Prevention National Program of Cancer Registries (CDC U58 DP005400). This study was also supported by the Markey Cancer Center Support Grant (NCI P30 CA177558) and T32 NIH Training Grant (T32CA160003). The Center for Clinical and Translational Sciences is funded through the NIH National Center for Advancing Translational Sciences (UL1TR001998).

Citation: Impact of the Affordable Care Act on Colorectal Cancer Screening, Incidence, and Survival in Kentucky. Journal of the American College of Surgeons. Available at: https://www.journalacs.org/article/S1072-7515(19)30046-8/fulltext.

  1. Wealth in America: Where are the richest and poorest states based on household income? USA Today. Available at: https://www.usatoday.com/story/money/economy/2018/10/08/wealth-america-household-income-richest-poorest-states/38051359/. Accessed January 30, 2019.
  2. Kentucky and the ACA's Medicaid expansion. Healthinsurance.org. Available at: https://www.healthinsurance.org/kentucky-medicaid/. Accessed January 30, 2019.

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 all 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 (.)

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