Towards reducing cancer burden within the Medicaid program: Impact of Medicaid expansion on cancer stage at diagnosis.
Authors: Koroukian Siran M. , Tsui Jennifer , Dong Weichuan , Yan Xiaoyu , Kim Uriel , Rose Johnie , Albert Jeffrey , Zanotti Kristine M. , Owusu Cynthia , Cooper Gregory 
Published: June 2021

1572 Background: Studies to date have shown post-Medicaid expansion (M-exp) decreases in the percentage of cancer patients who are uninsured and improvements in cancer stage at diagnosis in states that expanded Medicaid as part of the Affordable Care Act. However, most studies have examined impact of M-exp on stage outcomes at the population level, or among Medicaid and uninsured, rather than solely in the Medicaid population. Using cancer registry data from a non M-exp state (Georgia (GA)) and two M-exp states (Ohio (OH) and New Jersey (NJ)), we compared changes in cancer stage in patients on Medicaid, accounting for individual- and contextual-level characteristics at the Zip Code Tabulation Area (ZCTA) level. Methods: We used GA, OH, and NJ cancer registry data for individuals 20-64 years of age and diagnosed with incident invasive female breast (BC), cervical (CC), and colorectal cancer (CRC). Data spanned from 2010-2017 for GA and OH, and from 2011-2016 for NJ (for BC and CRC only), with 2014 marking the year in which Medicaid was expanded in OH and NJ. We retrieved demographic data (age, race/ethnicity, sex for CRC, insurance status, and cancer stage from the cancer registries), and obtained ZCTA-level data from the American Community Survey (e.g., income, education, and female-headed households). We defined late-stage diagnosis as regional- or distant- stage. We conducted multivariable logistic regression models by state and cancer site to examine changes in late-stage cancer diagnosis pre- and post-M-exp, accounting for individual- and ZCTA-level covariates. Results: The number of patients with incident cancer who were on Medicaid increased by 41.7% (n = 1757 to 2490), 59.6% (327 to 522), and 76.4% (953 to 1681) for BC, CC, and CRC cancers, respectively, in Ohio; by 92.4% (433 to 833) for BC and by over 100% for CRC (232 to 496) in NJ; but by 12.7% (662 to 746) among CRC patients in GA, where the number of BC and CC patients on Medicaid remained relatively stable. Adjusting for individual and contextual-level factors, the adjusted risk ratio (ARR and (95% Confidence Interval)) for late-stage disease was lowest for BC patients in OH (0.93 (0.87, 0.99)) and for CRC patients in GA (0.94 (0.89, 0.99)). The ARR for BC and CRC in NJ were not statistically significant, though they trended towards improvement. Similarly, changes in late-stage for CC were not statistically significant in OH or in GA. Conclusions: The increased number of cancer patients in Medicaid and the reductions in late-stage diagnosis observed may potentially translate into reduced, or at least stabilized, cancer-related morbidity and mortality burden among Medicaid beneficiaries over time. However, reductions in late-stage diagnosis were not consistent across cancer sites or states, possibly due to differences in population demographics, health behaviors, healthcare seeking patterns, and state-level cancer prevention efforts.