Study Explores Correlation Between Medicaid Expansion and Disease Stage and Time to Treatment Initiation in Head and Neck Cancer

A new study examined the relationship between Medicaid expansions as part of the Affordable Care Act (ACA) with stage at diagnosis and time to treatment initiation (TTI) for head and neck squamous cell carcinoma (HNSCC) patients.

“Medicaid expansions as part of the Patient Protection and Affordable Care Act (ACA) are associated with decreases in the percentage of uninsured patients who have received a new diagnosis of cancer. Little is known about the association of Medicaid expansions with stage at diagnosis and time to treatment initiation (TTI) for patients with head and neck squamous cell carcinoma (HNSCC),” the study authors explained.

The study authors performed a retrospective cohort study at Commission on Cancer-accredited facilities. A total of 90,789 HNSCC patients aged between 18 and 64 years who received a cancer diagnosis between Jan. 1, 2010, and Dec. 31, 2016, were identified using the National Cancer Database. The primary outcomes were health insurance coverage, stage at diagnosis, and TTI. The researchers figured out the absolute percentage change in health insurance coverage, crude and adjusted difference in differences (DD) in absolute percentage change in coverage, stage at diagnosis and TTI before (2010-2013) and after (2014-2016) the ACA took effect for Medicaid expansion and nonexpansion states.

Of the 90,789 HNSCC patients (mean [SD] age, 54.7 [7.0] years) included in the analysis, the majority (n = 70,907, 78.1%) were male, and most (n = 72,911, 80.3%) were non-Hispanic white. More than half (n = 52,142, 57.4%) were aged between 55 and 64 years, and about three-fifths (n = 54,940, 60.5%) lived in a Medicaid expansion state. Following the implementation of the ACA, the percentage of HNSCC patients with Medicaid, compared to nonexpansion states, increased more in expansion states (adjusted DD, 4.6 percentage points; 95% confidence interval [CI], 3.7–5.4 percentage points). In expansion states, compared to nonexpansion states, there was a greater increase in the percentage of patients with localized disease (defined as American Joint Committee on Cancer stage I-II) at diagnosis in the overall cohort (adjusted DD, 2.3 percentage points; 95% CI, 1.1–3.5 percentage points) as well as a subset of patients with nonoropharyngeal HNSCC (adjusted DD, 3.4 percentage points; 95% CI, 1.5–5.2 percentage points). In the entire study cohort, there was no significant different in mean TTI between expansion and nonexpansion states (adjusted DD, –12.7 percentage points; 95% CI, –27.4 to 4.2 percentage points), but improvements were observed in the nonoropharyngeal HNSCC subset (adjusted DD, –26.5 percentage points; 95% CI, 49.6 to –3.4 percentage points).

The study appeared in JAMA Otolaryngology-Head & Neck Surgery.

“Medicaid expansions were associated with a significantly greater increase in the percentage of Medicaid-insured patients with HNSCC, an increase in localized diseases at diagnosis for the overall cohort, and improved TTI for patients with nonoropharyngeal HNSCC. Selective state-level uptake of Medicaid expansion may exacerbate existing regional disparities in access to care and outcomes among patients with HNSCC,” concluded the study authors. “As data mature, additional research addressing the associations of Medicaid expansions with disparities and survival after diagnosis is warranted.”