Assessing Community Cancer Care After Insurance ExpanSionS
Condition: Cancer
Study type: Observational [Patient Registry]

Summary: 
      This innovative and timely study will measure the impact of Affordable Care Act (ACA)
      Medicaid expansions on cancer screenings and preventive services. To assess this natural
      policy experiment, the investigators will use electronic health record data from the
      Accelerating Data Value Across a National Community Health Center Network (ADVANCE) clinical
      data research network (CDRN) of the National Patient-Centered Clinical Research Network
      (PCORnet).
    

Detailed description: 
      Cancer morbidity and mortality is greatly reduced through screening and prevention, but
      uninsured patients are much less likely than insured patients to receive these evidence-based
      services as recommended. In addition, uninsured cancer survivors receive fewer primary and
      preventive care services than those with health insurance. Thus, it is hypothesized that
      Affordable Care Act (ACA) Medicaid expansions could substantially improve access to essential
      cancer preventive and screening services for previously uninsured patients, and facilitate
      better care for cancer survivors who gain health insurance. In 2012, the United States (US)
      Supreme Court ruled that states were not legally required to implement ACA Medicaid
      expansions, creating a unique natural experiment to test this hypothesis. By April 1, 2015,
      30 states and the District of Columbia had implemented expansions, and 20 states had not.
      This led to increased Medicaid enrollment by 26% in expansion states, compared to 8% in
      non-expansion states. Previous single-state Medicaid expansions led to increased utilization
      of healthcare services and improved health outcomes post-expansion. For example, in Oregon,
      cervical cancer screening rates were 18-19% higher among women who gained Medicaid in 2008,
      compared to those who remained uninsured. However, no previous assessments of state-specific
      expansions had concurrent control (non-expansion) states for comparison. Further, little is
      known about how Medicaid expansion impacts the delivery of recommended primary and preventive
      care services to cancer survivors, termed 'survivor care.'

      The investigators propose to use the ACA Medicaid expansion natural experiment to study the
      effect of state-level Medicaid expansion on rates of cancer screening and preventive services
      ('cancer prevention') and survivor care. Many patients likely to gain coverage through ACA
      Medicaid expansions receive primary care in community health centers (CHCs), our nation's
      healthcare 'safety net;' thus, the proposed analyses will use electronic health record (EHR)
      data from the ADVANCE clinical data research network (CDRN) of CHCs (ADVANCE is one of 11
      CDRNs in the national PCORnet data network). The ADVANCE CDRN has patient-level data from 476
      CHCs in 13 Medicaid expansion states (n=576,711 patients) and 242 CHCs in 8 non-expansion
      states (n=361,421 patients). This nationally unique data resource will allow us to measure
      outcomes in expansion versus non-expansion states, illuminating the impact of increased
      Medicaid opportunities on rates of cancer prevention and survivor care within the safety net.
      The investigators will also assess whether disparities in delivery of this care are reduced.
      Our specific aims for this study, titled "Assessing Community Cancer care after insurance
      ExpanSionS (ACCESS)," are to:

      Aim 1. Compare pre-post receipt of cancer prevention and screening among vulnerable CHC
      patients in Medicaid expansion versus non-expansion states.

      Hypothesis 1a: Cancer prevention and screening will significantly increase among CHC patients
      in expansion states, compared to those in non-expansion states.

      Hypothesis 1b: Racial/ethnic disparities in cancer prevention and screening will be
      significantly reduced in expansion states versus no change in non-expansion states.

      Aim 2. Compare pre-post insurance status, visits, and receipt of routine, recommended primary
      and preventive care among cancer survivors seen in CHCs in expansion versus non-expansion
      states.

      Hypothesis 2a: A higher percentage of uninsured cancer survivors will have gained insurance
      coverage in expansion states, compared to those in non-expansion states.

      Hypothesis 2b: Cancer survivors who are CHC patients in expansion states will have a
      significant increase in visits, visits paid by Medicaid, and survivor care relative to no
      change among patients in non-expansion states.
    

Intervention name(s): Medicaid Expansion
Intervention type(s): Other
Intervention description(s): There will be no direct intervention, but rather an observation of change based on whether a state expanded Medicaid or not
Observational model: Case-Control
Time perspective: Prospective
Sampling method: Non-Probability Sample
Study population: 
        Study eligible patients within electronic health record data from the ADVANCE CDRN of
        PCORnet
      
Keywords: healthcare access; healthcare utilization; preventive services; cancer survivors