Effect of Affordable Care Act’s Medicaid Expansion on Colorectal Cancer Screening and Survival in Kentucky
Kentucky has been one of the most successful states in reducing its uninsured rate, which happened in part through the Affordable Care Act’s Medicaid expansion that took effect on January 1, 2014. In the past, Kentucky has reported low rates of colorectal cancer screening, and has ranked among the highest states for incidence and mortality for the disease. One research team evaluated the impact of Medicaid expansion on the rates of colorectal cancer screening, incidence, and survival among the state’s low-income population.
The researchers found that the number of Medicaid patients who received screening after the expansion was more than triple the number of patients who were screened before the expansion. Additionally, patients with colorectal cancer relying on Medicaid exhibited improved survival after the expansion compared to before it was implemented. These findings were published by Gan et al in the Journal of the American College of Surgeons.
Medicaid Expansion
The Affordable Care Act’s Medicaid expansion provided insurance coverage to those at 138% of the federal poverty level. In Kentucky, the expansion meant that an additional 634,807 low-income people gained access to Medicaid. Many people in this population have a low level of education and don’t have easy access to a physician, especially the more rural Appalachian population in eastern Kentucky, explained lead study author Avinash Bhakta, MD, a colorectal surgeon at the University of Kentucky Markey Cancer Center, Lexington. Dr. Bhakta said he began treating more and more patients from Appalachian Kentucky, and he wanted to look further into how the Affordable Care Act could be related to the increase of patients he was treating.
“For me, it was bit of a wake-up call living in our society and seeing the population that I treat in Kentucky, particularly in Appalachia,” Dr. Bhakta said. “Many of these patients paved their own roads to come see me in Lexington. We didn’t really see much study on the effect of the Affordable Care Act Medicaid expansion, and with our population having the leading incidence and mortality rate of colorectal cancer in the country, we felt that it was an ideal population to study this potential impact.”
Methods
To conduct the study, the researchers obtained data on Kentucky’s colorectal cancer screening (per U.S. Preventative Services Task force guidelines), incidence, and outcomes from the Kentucky Hospital Discharge Database and the Kentucky Cancer Registry. The study population included 930,176 patients older than 20 years who underwent colorectal cancer screening from January 1, 2011, to December 31, 2016.
A total of 408,500 patients were screened before Medicaid expansion (January 1, 2011, to December 31, 2013), and 521,676 patients were screened after Medicaid expansion (January 1, 2014, to December 31, 2016). The researchers obtained measures including demographics; insurance coverage based on information at the time of diagnosis; socioeconomics (percentage below poverty status and high school education at the county level); and clinical information (tumor grade, stage at diagnosis, and survival).
Findings
One of the most significant results from this study, Dr. Bhakta said, was that patients with Medicaid demonstrated the highest increase in colorectal cancer screening. A total of 69,328 Medicaid patients received screening after the expansion compared with 20,980 patients who were screened before the expansion—an increase of 230%. Additionally, 43.7% more Appalachian patients received screening after the expansion.
When looking specifically at Medicaid patients, the researchers wrote, individuals in the 51 to 65 year age group had the highest improvement in screening, with an increase of 292.5%. Medicaid coverage of Appalachian patients increased by 199%.
From January 1, 2011, to December 31, 2016, 11,441 patients in Kentucky were diagnosed with colorectal cancer. When separated by insurance, the proportion of Medicaid patients diagnosed with colorectal cancer increased by 132.4% after Medicaid expansion, the authors wrote.
Dr. Bhakta said that increase was “a difficult number for me to swallow,” because with increased screening, there should be a drop in incidence. However, Dr. Bhakta noted that this research is still young. If the researchers follow the data for another 5 or 10 years, he anticipates seeing a drop in incidence.
The researchers also reported that after expansion, Medicaid patients exhibited improved survival compared with patients prior to expansion. The survival differences after expansion were evident in Medicaid patients after the first year and increased each year thereafter. Appalachian patients with Medicaid coverage had significantly improved survival after expansion compared with before expansion.
“We saw that month-to-month postexpansion, there was an improvement in survival from the preexpansion era in our Medicaid population,” Dr. Bhakta said. “We were able to follow many of these patients for up to 8 years, and we are continuing to keep track of them and their recurrences and overall survival.”
Implications
The most important takeaway from this study, Dr. Bhakta said, is that as more people get screened for colorectal cancer, more people will have improved survival. Now that the researchers have identified the problem, they will continue to gather data and find solutions for the state’s high mortality rate from colorectal cancer.
“We know that with increased screening, we’re able to get increased detection of earlier polyps,” he said. “The Medicaid expansion allowed us to get access to a lot of near-poor patients who would have otherwise not been able to get screened.”
Disclosure: Data collection activities of the Kentucky Cancer Registry are supported by the National Cancer Institute Surveillance Epidemiology and End Results Program and the Center for Disease Control and Prevention National Program of Cancer Registries. This study was also supported by the Markey Cancer Center Support Grant and T32 NIH Training Grant. The Center for Clinical and Translational Sciences is funded through the NIH National Center for Advancing Translational Sciences. The study authors' full disclosures can be found at journalacs.org.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
