Medicaid Expansion May Result in Earlier Colon Cancer Diagnosis, Study Says

The Affordable Care Act's Medicaid expansion for low-income individuals appears to lead to an earlier diagnosis of colorectal cancer, enhanced access to care, and improved surgical care for patients, according to a recent study.

In states that expanded Medicaid health insurance coverage in 2014, the 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, Pennsylvania.

"A paucity of studies looks at how Medicaid expansion affects cancer treatment and outcomes, as our study did," he said in a statement. "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. To date, 39 states have adopted Medicaid.

Access to health care may be especially important for colon cancer, the authors wrote. Colon and rectal cancer is the fourth most common US cancer and is increasing among adults younger than age 65.

The American Cancer Society has said that 1 in 3 Americans who should receive colon cancer screening do not, for reasons including inadequate health insurance.

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% of newly diagnosed cancer cases.

Hoehn and colleagues compared colon cancer data for 4438 patients residing in 19 states that implemented expansion in January 2014 with data for 6017 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.

Hoehn said they did not observe these delays in care in expansion states.

Other key differences in the 2015-2016 period were:

• 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.
• Patients traveled farther for care in expansion states, suggesting that patients who lived greater distances from hospitals could now obtain care because of coverage.
• 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. 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.

Their study, however, did not track survival rates or other long-term results.