A. B. Crocker1, A. Zeymo1,2, J. McDermott1, D. Xiao1, T. Watson4, T. DeLeire5, N. Shara2,3, K. S. Chan1,2, W. B. Al-Refaie1,4 1MedStar-Georgetown Surgical Outcomes Research Center,Washington, DC, USA 2MedStar Health Research Institute,Washington, DC, USA 3Georgetown-Howard Universities Center for Clinical and Translational Science,Washington, DC, USA 4Department of Surgery, MedStar-Georgetown University Hospital,,Washington, DC, USA 5Georgetown McCourt School of Public Policy,Washington, DC, USA
Introduction:
Pre-Affordable Care Act (ACA) Medicaid expansions have demonstrated inconsistent effects on cancer surgery utilization rates among racial minorities and low-income Americans. Currently, it remains unknown how Medicaid expansion coverage under the ACA will impact these vulnerable populations with long standing disparities in access and outcomes of surgical cancer care. Using a quasi-experimental design, this study seeks to examine whether Medicaid expansion differentially increased the utilization of surgical cancer care for low-income groups and racial minorities in states that expanded their Medicaid program relative to states that did not.
Methods:
A cohort of over 95,000 patients aged 18-64 years who underwent cancer surgery were examined in two Medicaid expansion states (Kentucky and Maryland) vs. two non-expansion states (Florida and North Carolina). This evaluation utilized merged data from the State Inpatient Database, American Hospital Association, and the Area Resource File from the Health Resources and Services Administration for the years 2012-2015. Poisson interrupted time series analysis (ITS) were performed to examine the impact of ACA Medicaid expansion on the utilization of surgical cancer care for the uninsured overall, low-income persons, and racial and ethnic minorities after adjusting for age, sex, Elixhauser comorbidity score, population- and provider-level characteristics.
Results:
Following Medicaid expansion, the share of Medicaid patients receiving surgical cancer care in expansion states increased by 56%, compared to an 11% decrease in non-expansion states (p <0.001). Simultaneously, the percentage of uninsured patients declined by 63.4% in expansion states relative to a 10% reduction in non-expansion states (p < 0.001). For persons from low-income zip codes, Medicaid expansion was associated with an immediate 24% increase in utilization (p = 0.002), relative to no significant change in non-expansion states. However, there were no significant trends observed post ACA expansion for racial and ethnic minorities in expansion vs. non-expansion states (Figure).
Conclusion:
In this quasi-experimental evaluation, Medicaid expansion was associated with greater utilization of cancer surgery by low-income Americans, but provided no preferential effects for racial minorities in expansion states. Beyond the availability of coverage, these early findings highlight the need for additional investigation to uncover other factors that contribute to racial disparities in surgical cancer care.
