Colorectal cancer (CRC) screening disparities persist among populations with limited health care access. Although Medicaid expansion and paid sick leave could address these barriers, there is limited data on the combined impact of these policies and CRC screening.

The authors conducted a difference-in-differences analysis using 2012-2018 Behavioral Risk Factor Surveillance System data. The study population included adults 50-75 years of age meeting preventive cancer screening guidelines during the study period. States were categorized into three groups: those with Medicaid expansion and paid sick leave (ME + SL), Medicaid expansion without paid sick leave (MEnoSL), and neither policy (NoME/NoSL). The pre-policy period was 2012-2014 and the post-policy period was 2015-2018. The outcome was the percent up-to-date with CRC screening. Survey-weighted logistic regression models accounted for individual- and state-level covariates and state-clustered standard errors.

Post-policy implementation, CRC up-to-date screening was 2.9 percentage points greater in ME + SL states compared to MEnoSL states (p < .001) and 4.2 percentage points greater compared to NoME/NoSL states (p = .018). These changes correspond to an estimated 352,343 and 1,087,140 fewer missed screenings between ME + SL and MEnoSL and NoME/NoSL states, respectively. The increased percent of up-to-date CRC screenings was associated with a reduction in colorectal cancer deaths: 8456 from ME + SL versus MEnoSL and 26,091 from ME + SL versus NoME/NoSL.

Medicaid expansion combined with paid sick leave was associated with a greater likelihood of being up-to-date with CRC screening compared to Medicaid expansion alone or neither policy.

Head and neck squamous cell carcinoma presents substantial symptom burdens in advanced stages, yet only a small fraction of patients receive palliative care (PC). Medicaid expansion and state-specific PC policies may influence PC uptake in this population.

This study evaluates the impact of Medicaid expansion and state-level PC laws on PC utilization among patients with stage III and IV HNC across the United States.

Using 2015-2020 National Cancer Database (NCDB) data, we identified deceased HNC patients with stage III or IV cancer and prognoses under 6 months. Using adjusted logistic regression, we analyzed the role of Medicaid expansion in PC utilization. Additionally, the Yale Palliative Care GPS was used to assess the distribution of state PC laws.

Of 10 305 eligible patients, 69.7% were from Medicaid expansion states. Medicaid expansion (aOR: 1.22, 95% CI: 1.01-1.49), higher Charles Comorbidity Index (CCI ≥ 3 vs. CCI = 1, aOR: 1.84, 95% CI: 1.16-2.81), and later years were associated with increased PC use. Geographic differences in PC law implementation were observed, with the West having the most enacted/passed laws while the Northeast had the highest PC utilization rate.

Medicaid expansion and specific state PC laws positively impact PC access for advanced HNC patients. These findings underscore the potential of policy interventions in enhancing PC accessibility and utilization among vulnerable cancer populations.

Racial minority groups experience disparities in cancer treatment and mortality. This study aimed to investigate the effect of Medicaid expansion on the existing racial disparities in all-cause mortality among patients with gastrointestinal malignancies.

A cross-sectional cohort study of patients with pancreatic ductal adenocarcinoma (PDAC), colorectal cancer (CRC), and gastric adenocarcinoma (GC) of any stage was conducted using data from the National Cancer Database (2009-2019). Using difference-in-difference (DID) analysis, the authors compared adjusted 2-year mortality rates among Black and White patients residing in states with expanded Medicaid benefits (MES) and non-MES before (2009-2013) and after (2014-2019) Medicaid expansion.

A total of 86,052 patients were included in this analysis, including 19,188 patients with PDAC, 60,404 with CRC, and 6460 with GC. Two-year mortality rates decreased among Black patients with PDAC residing in MES but not those residing in non-MES following Medicaid expansion (DID, -9.4%; 95% confidence interval [CI], -14.4% to -4.4%; p < .001). Mortality decreased more among Black and White patients with CRC in MES compared to those in non-MES following Medicaid expansion (DID, -2.9%; 95% CI, -5.7 to -0.04; p = .047 and DID, -4.2%; 95% CI, -5.8 to -2.5; p < .001, respectively). Black patients with GC in MES experienced a marked reduction in mortality compared to those in non-MES (DID, -7.7%, 95% CI, -16.1 to 0.56; p = .07).

Medicaid expansion was associated with a greater reduction in 2-year mortality rates among Black patients residing in MES compared to those residing in non-MES. Existing racial disparities in mortality remained the same or worsened in non-MES but were mitigated in MES following Medicaid expansion in almost all comparisons.

Medicaid expansion afforded increased healthcare access to low-income Americans contributing to a positive impact on cancer outcomes. However, it is unclear if these benefits were mainly due to enhanced access to cancer screening and earlier diagnosis versus access to cancer treatment METHODS: The National Cancer Database (NCDB) was queried between 2010 and 2021 for Medicaid and uninsured patients with GI malignancies. Patients were stratified by screenable (SGI) and non-screenable (NGI) cancers and expansion state (ES) categories: early (EES) and late (LES) adopters, and non-expansion state (NES) cohorts. Statistical analyses, including difference-in-difference (DiD) and adjusted models, assessed the impact of Medicaid expansion on stage at diagnosis.

There were 230,159 pre-expansion and 539,028 post-expansion patients. There was an increase in Medicaid coverage (14.8 % vs. 11.1 %) and a concomitant decline in the uninsured population (5.3 % vs. 8.2 %) in the post-expansion era. For SGI cancers, Medicaid expansion was associated with significantly lower mean stage at diagnosis (DiD Coef. -0.12; p < 0.01). For NGI cancers, Medicaid expansion was associated with a lower mean stage at diagnosis but with much smaller coefficient (DiD Coef. -0.015; p < 0.01). Comparing EES and LES to NES, EES had more impact on lower mean stage at diagnosis (vs NES DiD Coef. -0.16; p < 0.01) compared to LES (vs NES DiD Coef. -0.02; p = 0.04) for SGI cancers. For NGI cancers, there was a modest reduction in mean stage at diagnosis only for EES (vs NES DiD Coef. -0.04; p < 0.01).

Medicaid expansion, particularly for SGI cancers and early adopters, had a profound impact in lowering the mean stage at diagnosis. This emphasizes that long-term advantages of providing access to preventive care and screening, and thus earlier treatment, may be one of the main mechanisms of Medicaid expansion on improving cancer outcomes for GI malignancies.

To establish the benefits of Medicaid expansion under the Affordable Care Act 2010 for gastrointestinal cancer patients particularly in screening.

Background: Although the Patient Protection and Affordable Care Act (ACA) has been associated with increased Medicaid coverage among prostate cancer patients, the association between Medicaid expansion with risk group at diagnosis, time to treatment initiation (TTI), and the refusal of locoregional treatment (LT) among patients requires further exploration. Methods: Using the National Cancer Database, we performed a retrospective cohort analysis of all patients aged 40 to 64 years diagnosed with localized prostate cancer from 2011 to 2016. Difference-in-difference (DID) analysis was used to compare changes in insurance status, risk group at diagnosis, TTI, and the refusal of LT among patients residing in Medicaid expansion versus non-expansion states. In a secondary analysis, we used DID to compare changes in the above outcomes among racial minorities versus White patients living in expansion states. Results: Of the 112,434 patients with prostate cancer in our analysis, 50,958 patients lived in Medicaid expansion states, and 61,476 patients lived in non-expansion states. In the adjusted analysis, we found that the proportion of uninsured patients (adjusted DID: -0.87%; 95% confidence interval [95% CI]: -1.28 to -0.46) and patients who refused radiation therapy (adjusted DID: -0.71%; 95% CI: -0.95 to -0.47) decreased more in expansion states compared to non-expansion states. Similarly, we observed that the racial disparity of select outcomes in expansion states narrowed, as racial minorities experienced larger absolute decreases in uninsured status and the refusal of radiation therapy (RT) regimens than White patients following ACA implementation (p < 0.01 for all). However, residence in a Medicaid expansion state was not associated with changes in risk group at diagnosis, TTI, nor the refusal of LT (p > 0.01 for all); racial disparities in TTI were also exacerbated in expansion states following ACA implementation. Conclusions: The association between Medicaid expansion and prostate cancer outcomes and disparities remains unclear. While ACA implementation was associated with increased insurance coverage and decreased refusal of RT, there was no significant association with earlier risk group at diagnosis, TTI within 180 days, or refusal of LT. Similarly, racial minorities in expansion states had larger decreases in uninsured status and the refusal of RT regimens, as well as smaller increases in intermediate-/high-risk disease at presentation than White patients following ACA implementation, but experienced no significant changes in TTI. More research is needed to understand how Medicaid expansion affects cancer outcomes and whether these effects are borne equitably among different populations.

The burden of early onset colorectal cancer (EOCRC) falls disproportionately on minorities and individuals in specific geographic regions. While these disparities are likely multi-factorial, access to high-quality health care plays a significant role. We sought to determine if Medicaid expansion is associated with reducing racial disparities in EOCRC detection in Hispanics and non-Hispanic Blacks (NHB), compared to non-Hispanic Whites (NHW).

Analysis of data from National Cancer Database was undertaken to compare incidence of EOCRC among those aged 40-49 between Medicaid expansion states (ES) and non-expansion states (NES) by racial/ethnic groups. Data was classified by race (NHW, NHB, or Hispanic), state of residence (ES or NES), and time (pre- or post-expansion). The primary outcome was change in incidence rate of EOCRC among racial/ethnic groups, according to whether patients resided in Medicaid expansion or non-expansion states.

Among Hispanics, the ES showed a significant increase in EOCRC incidence post expansion as compared to NES (p = 0.03). The rate of increase in annual incidence of EOCRC among Hispanics was 4.3% per year (pre-expansion) and 9.8% (post-expansion) for ES; and 6.4% (pre-expansion) and 1% (post-expansion) in NES. However, no difference was noted among NHB (p = 0.33) and NHW (p = 0.94).

Medicaid expansion has improved detection rates of EOCRC in ES especially in Hispanic population. This is the first study to demonstrate the effect of Medicaid expansion on the incidence of EOCRC. Based on our study findings we suggest that racial and ethnic disparities should be considered in the earlier CRC screening debates.

This study investigated the potential associations between neighborhood characteristics, rurality, ethnicity/race, and breast cancer screening outcomes in designated Health Professional Shortage Areas in Central Texas. Limited access to preventive medical care can impact screening rates and outcomes. Previous research on the effects of factors such as rurality, neighborhood socioeconomic status, and education level on cancer prevention behaviors has yielded inconsistent results.

We analyzed data from a state-funded breast and cervical cancer screening programs for disadvantaged and medically underserved individuals. A mixed-effects logistic regression model was used to assess the impact of residency characteristics (rurality, educational attainment, unemployment, and poverty) on abnormal breast cancer screening outcomes, with individual level (age, ethnicity, race, and education) as control variables.

During the studied time, there were 1,139 women screened and 134 abnormal mammograms found. Residency characteristics were not significantly associated with abnormal mammography outcomes at 0.05. However, individual factors are strongly associated with abnormal screening results. Non-Hispanic or Latino white women had increased odds of abnormal clinical outcomes compared with Hispanic or Latino women (OR = 2.03, CI 1.25-3.28; p = 0.004). Additionally, women residing in counties with more than 30% of the population completing college had increased odds of abnormal mammogram outcomes compared with counties with less than 15% college attainment (OR = 2.89, CI 0.99-8.38; p = 0.051).

This study found a significant correlation between area-level educational characteristics and abnormal mammography outcomes. Future research should explore the contextual risk factors influencing breast cancer occurrence and develop targeted interventions for this population.

Colorectal cancer screening rates remain suboptimal, particularly among low-income populations. Our objective was to evaluate the long-term effects of Medicaid expansion on colorectal cancer screening.

This cross-sectional study analyzed data from 354,384 individuals aged 50-64 with an income below 400% of the federal poverty level (FPL), who participated in the Behavioral Risk Factors Surveillance System from 2010 to 2018. A difference-in-difference analysis was employed to estimate the effect of Medicaid expansion on colorectal cancer screening. Subgroup analyses were conducted for individuals with income up to 138% of the FPL and those with income between 139% and 400% of the FPL. The effect of Medicaid expansion on colorectal cancer screening was examined during the early, mid, and late expansion periods.

The primary outcome was the likelihood of receiving colorectal cancer screening for low-income adults aged 50-64.

Medicaid expansion was associated with a significant 1.7 percentage point increase in colorectal cancer screening rates among adults aged 50-64 with income below 400% of the FPL (p < 0.05). A significant 2.9 percentage point increase in colorectal cancer screening was observed for those with income up to 138% the FPL (p < 0.05), while a 1.5 percentage point increase occurred for individuals with income between 139% and 400% of the FPL. The impact of Medicaid expansion on colorectal cancer screening varied based on income levels and displayed a time lag for newly eligible beneficiaries.

Medicaid expansion was found to be associated with increased colorectal cancer screening rates among low-income individuals aged 50-64. The observed variations in impact based on income levels and the time lag for newly eligible beneficiaries receiving colorectal cancer screening highlight the need for further research and precision public health strategies to maximize the benefits of Medicaid expansion on colorectal cancer screening rates.

Studies have suggested Medicaid expansion enacted in 2014 has resulted in a reduction in overall cardiovascular disease (CVD) mortality in the United States. However, it is unknown whether Medicaid expansion has a similar effect across race-ethnicity and sex. We investigated the effect of Medicaid expansion on CVD mortality across race-ethnicity and sex.

Data come from the behavioral risk factor surveillance system and the US Centers for Disease Control's Wide-ranging Online Data for Epidemiologic Research, spanning the period 2000-2019. We used the generalized synthetic control method, a quasi-experimental approach, to estimate effects.

Medicaid expansion was associated with -5.36 (mean difference [MD], 95% confidence interval [CI] = -22.63, 11.91) CVD deaths per 100,000 persons per year among Blacks; -4.28 (MD, 95% CI = -30.08, 21.52) among Hispanics; -3.18 (MD, 95% CI = -8.30, 1.94) among Whites; -5.96 (MD, 95% CI = -15.42, 3.50) among men; and -3.34 (MD, 95% CI = -8.05, 1.37) among women. The difference in mean difference (DMD) between the effect of Medicaid expansion in Blacks compared with Whites was -2.18; (DMD, 95% CI = -20.20, 15.83); between that in Hispanics compared with Whites: -1.10; (DMD, 95% CI = -27.40, 25.20) and between that in women compared with men: 2.62; (DMD, 95% CI = -7.95, 13.19).

Medicaid expansion was associated with a reduction in CVD mortality overall and in White, Black, Hispanic, male, and female subpopulations. Also, our study did not find any difference or disparity in the effect of Medicaid on CVD across race-ethnicity and sex-gender subpopulations, likely owing to imprecise estimates.

This study estimated the association between the 2014 Medicaid expansion and asthma-related prescription drug utilization and expenditures among low-income adult participants with asthma, including those with uncontrolled asthma, in the United States.

In this national analysis, using a pooled dataset from 2007-2018 Medical Expenditure Panel Surveys (MEPS), regression discontinuity (D-RD) analyses estimated the association between Medicaid expansion and utilization of and expenditures for asthma-related prescription drugs among participants with asthma aged 26-64 with incomes below vs. at/above 138% of the federal poverty level (FPL). A sub-sample analysis was also conducted among participants with uncontrolled asthma. Utilization and expenditure outcomes were estimated using two-part models with logit as the first part and generalized linear models as the second part.

Utilization of and total cost for asthma-related prescription drugs increased by 1.89 fills (p < 0.001) and $306.59 (p < 0.001) among participants with asthma with income below 138% FPL after Medicaid expansion. The utilization and total cost of both short-acting bronchodilators and inhaled corticosteroids (ICSs) increased after Medicaid expansion among participants with asthma with incomes below 138% FPL. Among participants with uncontrolled asthma with incomes below 138% FPL, utilization and expenditures increased after Medicaid expansion for all asthma-related prescription drugs and short-acting bronchodilators.

Medicaid expansion was associated with increased utilization of and total expenditures for both quick-relief and preventive asthma medications among all low-income participants with asthma, but not with utilization of preventive medications among those with uncontrolled asthma.

Structural racism and discrimination (SRD) are important upstream determinants of health perpetuated by discriminatory laws and policies. Therefore, measuring SRD and its impact on health is critical to developing interventions that address resultant health disparities. We aimed to identify gastrointestinal (GI) or liver studies that report measures of SRD or interventions to achieve health equity in these domains by addressing upstream determinants of health.

We conducted a scoping review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses scoping reviews guidelines. Studies that used an SRD measure or examined an upstream intervention in GI or liver disease were included. Studies that described health disparities in GI or liver conditions without mentioning SRD were excluded. Study characteristics, findings, and limitations were extracted.

Forty-six articles (19 studies using SRD measures and 27 studies of upstream interventions) were identified. Measures of residential racial segregation were reported most frequently. SRD was associated with poorer health outcomes for racial and ethnic minority populations. Although upstream intervention studies focused primarily on policies related to colon cancer screening and organ graft allocation, racial and ethnic disparities often persisted post-intervention.

To achieve health equity in GI and liver conditions, there is an urgent need for research that goes beyond describing health disparities to incorporating measures of SRD and implementing interventions that address this understudied determinant of health.

Colorectal cancer (CRC) remains a relevant public health problem. Current research suggests that racial, economic and geographic disparities impact access. Despite the expansion of Medicaid eligibility as a key component of the Affordable Care Act (ACA), there is a dearth of information on the utilization of newly gained access to CRC screening by low-income individuals. This study investigates the impact of the ACA's Medicaid expansion on utilization of the various CRC screening modalities by low-income participants. Our working hypothesis is that Medicaid expansion will increase access and utilization of CRC screening by low-income participants.

To investigate the impact of the Affordable Care Act and in particular the effect of Medicaid expansion on access and utilization of CRC screening modalities by Medicaid state expansion status across the United States.

This was a quasi-experimental study design using data from the Behavioral Risk Factor Surveillance System, a large health system survey for participants across the United States and with over 2.8 million responses. The period of the study was from 2011 to 2016 which was dichotomized as pre-ACA Medicaid expansion (2011-2013) and post-ACA Medicaid expansion (2014-2016). The change in utilization of access to CRC screening strategies between the expansion periods were analyzed as the dependent variables. Secondary analyses included stratification of the access by ethnicity/race, income, and education status.

A greater increase in utilization of access to CRC screening was observed in Medicaid expansion states than in non-expansion states [+2.9%; 95% confidence interval (95%CI): 2.12, 3.69]. Low-income participants showed a +4.02% (95%CI: 2.96, 5.07) change between the expansion periods compared with higher income groups +3.19% (1.70, 4.67). Non-Hispanic Whites and Hispanics [+3.01% (95%CI: 2.16, 3.85) vs +5.51% (95%CI: 2.81, 8.20)] showed a statistically significant increase in utilization of access but not in Non-Hispanic Blacks, or Multiracial. There was an increase in utilization across all educational levels. This was significant among those who reported having a high school graduate degree or more +4.26 % (95%CI: 3.16, 5.35) compared to some high school or less +1.59% (95%CI: -1.37, 4.55).

Medicaid expansion under the Affordable Care Act led to an overall increase in self-reported use of CRC screening tests by adults aged 50-64 years in the United States. This finding was consistent across all low-income populations, but not all races or levels of education.

Despite their higher incidence of colorectal cancer, ethnoracial minority and low-income patients have reduced access to elective colorectal cancer surgery. Although the Affordable Care Act's Medicaid expansion increased screening of colonoscopies, its effect on disparities in elective colorectal cancer surgery remains unknown.

This study assessed the effects of Medicaid expansion on elective colorectal cancer surgery rates overall and by race-ethnicity and income.

Using the 2012 to 2015 State Inpatient Databases, a retrospective cohort study was conducted.

State Inpatient Databases from 3 expansion states (Maryland, New Jersey, and Kentucky) and 2 nonexpansion states (Florida and North Carolina) were used.

This study examined 22,304 adult patients aged 18 to 64 years who underwent colorectal cancer surgery.

Using interrupted time series analysis, the effect of Medicaid expansion on the odds of elective colorectal cancer surgery was assessed.

Elective vs nonelective surgery rates remained unchanged overall (70.2% vs 70.7%, p = 0.63) and in ethnoracial minorities in expansion states (whites from 72.8% to 73.8% pre to post, p = 0.40 and non-white from 64.0% to 63.1% pre to post, p = 0.67). There was an instantaneous increase in odds of elective surgery in expansion vs nonexpansion states at policy implementation (adjusted OR 1.37; 95% CI, 1.05-1.79; p = 0.02), but it subsequently decreased (combined adjusted OR 0.95; 95% CI, 0.92-0.99; p = 0.03). Elective surgery rates were also unchanged among ethnoracial minorities (instantaneous changes in expansion states, combined effect 1.06; pre-trend 1.01 vs post-trend 0.98) and low-income persons in expansion states (pre-trend 1.03 vs post-trend 0.97) (for all, p > 0.1).

The study was limited to 5 states. Although patients may have increased access to cancer screening services and surgery after expansion, the State Inpatient Databases only provide information on patients who underwent surgery.

Despite gains in screening, Medicaid expansion was not associated with reductions in known ethnoracial or income-based disparities in elective colorectal cancer surgery rates. Expanding access to colorectal cancer surgery for underserved populations likely requires attention to provider and health system factors contributing to persistent disparities. See Video Abstract at http://links.lww.com/DCR/C217 .

ANTECEDENTES: A pesar de su mayor incidencia de cáncer colorrectal, los pacientes de minorías etnoraciales y de bajos ingresos tienen un acceso reducido a la cirugía electiva de cáncer colorrectal. Aunque la expansión de Medicaid de la Ley del Cuidado de Salud a Bajo Precio aumentó las colonoscopias de detección, aún se desconoce su efecto sobre las disparidades en la cirugía electiva de cáncer colorrectal.OBJETIVO: Este estudio evaluó los efectos de la expansión de Medicaid en las tasas de cirugía electiva de cáncer colorrectal en general y por raza, etnia e ingresos.DISEÑO: Utilizando las bases de datos estatales de pacientes hospitalizados de 2012-2015, se realizó un estudio de cohorte retrospectivo.CONFIGURACIÓN: Se utilizaron bases de datos estatales de pacientes hospitalizados de tres estados en expansión (Maryland, Nueva Jersey, Kentucky) y dos estados sin expansión (Florida, Carolina del Norte).PACIENTES: Este estudio examinó a 22,304 pacientes adultos de 18 a 64 años que se sometieron a cirugía de cáncer colorrectal.RESULTADO PRINCIPAL: Mediante el análisis de series de tiempo interrumpido, se evaluó el efecto de la expansión de Medicaid en las probabilidades de cirugía electiva de cáncer colorrectal.RESULTADOS: Las tasas de cirugía electiva frente a no electiva permanecieron sin cambios en general (70,2% frente a 70,7%, p = 0,63) y en las minorías etnoraciales en los estados de expansión (blancos del 72,8% al 73,8 % antes y después, p = 0,40 y no blancos del 64,0% al 63,1% pre a post, p = 0,67). Hubo un aumento instantáneo en las probabilidades de cirugía electiva en los estados de expansión frente a los de no expansión en la implementación de la política (OR ajustado 1,37, IC del 95%, 1,05-1,79, p = 0,02), pero disminuyó posteriormente (OR ajustado combinado 0,95, 95% IC, 0,92-0,99, p = 0,03). Las tasas de cirugía electiva también se mantuvieron sin cambios entre las minorías etnoraciales (cambios instantáneos en los estados de expansión, efecto combinado 1,06; antes de la tendencia 1,01 frente a la postendencia 0,98) y las personas de bajos ingresos en los estados de expansión (antes de la tendencia 1,03 frente a la postendencia 0,97; para todos, p > 0,1).LIMITACIONES: El estudio se limitó a cinco estados. Si bien los pacientes pueden tener un mayor acceso a los servicios de detección de cáncer y la expansión posterior a la cirugía, la base de datos de pacientes hospitalizados del estado solo brinda información sobre los pacientes que se sometieron a cirugía.CONCLUSIONES: A pesar de los avances en la detección, la expansión de Medicaid no se asoció con reducciones en las disparidades etnoraciales o basadas en los ingresos conocidas en las tasas de cirugía electiva de cáncer colorrectal. Ampliar el acceso a la cirugía del cáncer colorrectal para las poblaciones desatendidas probablemente requiera atención a los factores del proveedor y del sistema de salud que contribuyen a las disparidades persistentes. Consulte el Video Resumen en http://links.lww.com/DCR/C217 . (Traducción-Dr. Yesenia.Rojas-Khalil ).

Mortality rates from colorectal cancer have declined over the past decades owing to population-based life-saving screening interventions. However, screening inequalities continue among racial and ethnic minorities despite having a higher disease burden. In this study, we assessed the patterns of up-to-date colorectal cancer screening rates among racial/ethnic groups across the U.S. Census Bureau Divisions.

This population-based cross-sectional study used weighted data from 4 cycles of the Behavioral Risk Factors Surveillance System (2014, 2016, 2018, and 2020) of adults aged 50‒75 years without a previous diagnosis of colorectal cancer. The primary outcome was guideline-recommended up-to-date colorectal cancer screening. We used logistic regression models to examine temporal trends in up-to-date colorectal cancer screening from 2014 to 2020. In addition, we conducted detailed descriptive statistics of up-to-date screening rates, comparing trends in 2020 with those in 2014 overall by race/ethnicity and U.S. census divisions.

The overall proportion of individuals with up-to-date colorectal cancer screening increased from 66.5% in 2014 to 72.5% in 2020 (p<0.001). For racial/ethnic subgroups, from 2014 to 2020, screening rates increased significantly among non-Hispanic Whites (68.5%‒74.5%, p<0.001), non-Hispanic Blacks (68.0%‒74.6%, p<0.001), and Hispanics (51.5%‒62.8%, p<0.001). However, increases were not observed in all U.S. Census Bureau Divisions.

Although colorectal cancer screening rates improved over time, they fall short of the 80% target. Substantial racial/ethnic and geographic disparities remain. Future studies investigating the factors influencing these disparities are needed.

It is unclear if Medicaid expansion improved access to surgical resection for hepatopancreatobiliary (HPB) and gastrointestinal (GI) cancers.

This was a quasi-experimental, cohort study using difference-in-difference analysis to evaluate differences in surgical resection for HPB/GI cancers in the post-Medicaid expansion era compared to the pre-Medicaid expansion era among patients residing in states that had Medicaid expansion versus not.

During the pre- (2011-2013) and post-Medicaid expansion (2015-2017) eras, there were 49,954 patients between the ages of 40-64 who had liver cancer (n = 19,384; 38.8%), pancreatic cancer (n = 14,351; 28.7%), colorectal liver metastasis (n = 7566; 15.1%), or gastric cancer (n = 8653; 17.3%). 43.2% resided in expansion states (n = 21,577). There were no significant differences in the overall rates of surgical resection between expansion and non-expansion states before and after Medicaid expansion.

Medicaid expansion did not impact surgical resection for HPB/GI cancers.

Colorectal cancer screening continuously decreased its mortality and incidence. In 2010, the Affordable Care Act extended Medicaid eligibility to low-income and childless adults. Some states elected to adopt Medicaid at different times while others chose not to. Past studies on the effects of Medicaid expansion on colorectal cancer screening showed equivocal results based on short-term data following expansion.

To examine the long-term impact of Medicaid expansion on colorectal cancer screening among its targeted population at its decade mark.

Behavioral Risk Factor Surveillance System data were extracted for childless adults below 138% federal poverty level in states with different Medicaid expansion statuses from 2012 to 2020. States were stratified into very early expansion states, early expansion states, late expansion states, and non-expansion states. Colorectal cancer screening prevalence was determined for eligible respondents. Difference-in-differences analyses were used to examine the effect of Medicaid expansion on colorectal cancer screening in states with different expansion statuses.

Colorectal cancer screening prevalence in very early, early, late, and non-expansion states all increased during the study period (40.45% vs. 48.14%, 47.52% vs 61.06%, 46.06% vs 58.92%, and 43.44% vs 56.70%). Difference-in-differences analysis showed significantly increased CRC screening prevalence in very early expansion states during 2016 compared to non-expansion states (Crude difference-in-differences + 16.45%, p = 0.02, Adjusted difference-in-differences + 15.9%, p = 0.03). No statistical significance was observed among other years and groups.

Colorectal cancer screening increased between 2012 and 2020 in all states regardless of expansion status. However, Medicaid expansion is not associated with long-term increased colorectal cancer screening prevalence.

The 2010 Patient Protection and Affordable Care Act mandated preventive screening coverage and provided support to participating states for Medicaid coverage. The association of Medicaid expansion with colon cancer stage at diagnosis is unknown.

This study aimed to determine whether the proportion of patients diagnosed with early stage colon cancer changed over time within states that expanded Medicaid compared with nonexpansion states.

This is a cross-sectional cohort study.

This study evaluated multicenter registry data from the National Cancer Database (2006-2016).

There were 25,462 uninsured or Medicaid-insured patients with newly diagnosed colon cancer who resided in 2014 Medicaid expansion or nonexpansion states.

This study assessed the annual proportion of patients with early stage (I-II) versus late stage (III-IV) colon cancer.

A total of 10,289 patients were identified in expansion states and 15,173 patients in nonexpansion states. Cohorts were similar in age (median 55 years) and sex (46.7% female). A greater proportion of patients in nonexpansion states were Black (33.4% vs 24.0%) and resided in a zip code with median income <$38,000 (39.7% vs 28.2%) and lower educational status (37.4% vs 28.1%). In 2006, the proportions of patients with early stage colon cancer in expansion and nonexpansion cohorts were similar (33.2% vs 32.5%). The proportion of patients with early stage colon cancer within nonexpansion states declined by 0.8% per year after 2014, whereas the proportion within expansion states increased by 0.9% per year after 2014 ( p < 0.05). By 2016, the absolute difference in the propensity-adjusted proportion of early stage colon cancer was 8.8% (39.7% vs 30.9%, p < 0.001).

National Cancer Database data are obtained only from Commission on Cancer-accredited sites and are not population based.

After Medicaid expansion in 2014, the proportion of patients diagnosed and treated at Commission on Cancer-accredited facilities with early stage colon cancer increased within expansion states and decreased in nonexpansion states. Increase in insurance coverage may have facilitated earlier diagnosis among patients in expansion states. See Video Abstract at http://links.lww.com/DCR/B804 .

ANTECEDENTES:La Ley del Cuidado de Salud a Bajo Precio del 2010 ordenó la cobertura de exámenes preventivos y brindó apoyo a los estados participantes para la cobertura de Medicaid. Se desconoce la asociación de la expansión de Medicaid con el estadio del cáncer de colon en el momento del diagnóstico.OBJETIVO:Determinar si la proporción de pacientes diagnosticados con cáncer de colon en estadio temprano cambió con el tiempo dentro de los estados que expandieron Medicaid en comparación con los estados sin expansión.DISEÑO:Estudio de cohorte transversal.ENTORNO CLINICO:Datos de registro multicéntrico de la Base de datos nacional de cáncer (2006-2016).PACIENTES:Había 25,462 pacientes sin seguro o asegurados por Medicaid con cáncer de colon recién diagnosticado. Exposición: Residencia en estados de expansión o no expansión de Medicaid en el 2014.PRINCIPALES MEDIDAS DE RESULTADO:Proporción anual de pacientes con cáncer de colon en estadio temprano (I-II) versus tardío (III-IV).RESULTADOS:Se identificaron un total de 10.289 pacientes en estados de expansión y 15.173 pacientes en estados de no expansión. Las cohortes fueron similares en edad (mediana de 55 años) y sexo (46,7% mujeres). Una mayor proporción de pacientes en estados sin expansión eran de raza negra (33,4% vs 24,0%) y residían en un código postal con ingresos medios <$38 000 (39,7% vs 28,2%) y un nivel educativo más bajo (37,4% vs 28,1%). En el 2006, las proporciones de pacientes con cáncer de colon en estadio temprano en cohortes en expansión y sin expansión fueron similares (33,2% vs 32,5%). La proporción de pacientes con estadio temprano dentro de los estados sin expansión disminuyó en un 0,8% por año después del 2014, mientras que la proporción dentro de los estados de expansión aumentó en un 0,9% por año después del 2014 (p <0,05). Para el 2016, la diferencia absoluta en la proporción ajustada por propensión de cáncer de colon en estadio temprano fue de 8.8% (39.7% vs 30.9%, p <0.001).LIMITACIONES:Los datos de la Base de datos nacional de cáncer se obtienen únicamente de los sitios acreditados por la Comisión de cáncer y no se basan en la población.CONCLUSIONES:Después de la expansión de Medicaid en el 2014, la proporción de pacientes diagnosticados y tratados en instalaciones acreditadas por la Comisión de Cáncer en pacientes con cáncer de colon en estadio temprano aumentó dentro de los estados de expansión y disminuyó en los estados de no expansión. El aumento de la cobertura del seguro puede haber facilitado un diagnóstico más temprano entre los pacientes en estados de expansión. Consulte Video Resumen en http://links.lww.com/DCR/B804 . (Traducción- Dr. Francisco M. Abarca-Rendon ).

The Affordable Care Act implemented optional Medicaid expansion starting in 2014, but the association between Medicaid expansion and gynecologic cancer survival is unknown.

To evaluate the impact of Medicaid expansion by comparing 2-year survival among gynecologic cancers before and after 2014 in states that did and did not expand Medicaid using a difference-in-difference analysis.

We searched the National Cancer Database for women aged 40 to 64 years, diagnosed with a primary gynecologic malignancy (endometrial, ovarian, cervical, vulvar, and vaginal) between 2010 and 2016. We used a quasiexperimental difference-in-difference multivariable Cox regression analysis to compare 2-year survival between states that expanded Medicaid in January 2014 and states that did not expand Medicaid as of 2016. We performed univariable subgroup difference-in-difference Cox regression analyses on the basis of stage, income, race, ethnicity, and geographic location. Adjusted linear difference-in-difference regressions evaluated the proportion of uninsured patients on the basis of expansion status after 2014. We evaluated adjusted Kaplan-Meier curves to examine differences on the basis of study period and expansion status.

Our sample included 169,731 women, including 78,669 (46.3%) in expansion states and 91,062 (53.7%) in nonexpansion states. There was improved 2-year survival on adjusted difference-in-difference Cox regressions for women with ovarian cancer in expansion than in nonexpansion states after 2014 (hazard ratio, 0.88; 95% confidence interval, 0.82-0.94; P<.001) with no differences in endometrial, cervical, vaginal, vulvar, or combined gynecologic cancer sites on the basis of expansion status. On univariable subgroup difference-in-difference Cox analyses, women with ovarian cancer with stage III-IV disease (P=.008), non-Hispanic ethnicity (P=.042), those in the South (P=.016), and women with vulvar cancer in the Northeast (P=.022), had improved 2-year survival in expansion than in nonexpansion states after 2014. In contrast, women with cervical cancer in the South (P=.018) had worse 2-year survival in expansion than in nonexpansion states after 2014. All cancer sites had lower proportions of uninsured patients in expansion than in nonexpansion states after 2014.

There was a significant association between Medicaid expansion and improved 2-year survival for women with ovarian cancer in states that expanded Medicaid after 2014. Despite improved insurance coverage, racial, ethnic, and regional survival differences exist between expansion and nonexpansion states.

Medicaid expansion has improved healthcare coverage and preventive health service use. To what extent this has resulted in earlier stage colorectal cancer diagnoses and impacted perioperative outcomes is unclear.

This was a retrospective difference-in-difference study using the National Cancer Database on adults (40-64) with Medicaid or no insurance, diagnosed with colorectal adenocarcinomas before (2010-2013) and after (2015-2018) expansion. The primary outcome was early-stage (American Joint Committee on Cancer Stage 0-1) diagnosis. The secondary outcomes were rate of local excision, emergency surgery, postoperative length of stay, rates of minimally invasive surgery, postoperative mortality, and overall survival (OS).

Medicaid expansion was associated with an increase in early-stage diagnoses for patients with colorectal cancers (odds ratio [OR]: 1.28, 95% confidence interval [CI]: 1.15-1.43), an increase in local excision (OR: 1.39, 95% CI: 1.13-1.69), and a decreased rate of emergent surgery (OR: 0.85, 95% CI: 0.75-0.97) and 90-day mortality (OR: 0.75, 95% CI: 0.59-0.97). Additionally, patients in expansion states postexpansion had an improved 5-year OS (hazard ratio: 0.88, 95% CI: 0.83-0.94).

Insurance coverage expansion may be particularly important for optimizing stage of diagnosis, subsequent survival, and perioperative outcomes for socioeconomically vulnerable patients.

Medicaid expansion has led to earlier stage diagnoses in several cancers but has not been studied in hepatocellular carcinoma (HCC), a disease with complex risk factors. We examined the effect of Medicaid expansion on the diagnosis of HCC and associations with county-level social vulnerability.

Patients with HCC <65 years of age were identified from the SEER database (2010-2016). County-level social vulnerability factors were obtained from the CDC SVI and BRFSS. A Difference-in-Difference analysis evaluated change in early-stage diagnoses (stage I-II) between expansion and non-expansion states. A Difference-in-Difference-in-Difference analysis evaluated expansion impact among counties with higher proportions of social vulnerability.

Of 19,751 patients identified, 81.5% were in expansion states. Uninsured status decreased in expansion states (6.3%-2.4%, p < 0.0001) and remained unchanged in non-expansion states (12.7%-14.8%, p = 0.43). There was no significant difference in the incidence of early-stage diagnoses between expansion states and non-expansion states. Results were consistent when accounting for social vulnerability.

Medicaid expansion was not associated with earlier stage diagnoses in patients with HCC, including those with higher social vulnerability. Unlike other cancers, expanded access did not translate into higher utilization of care in HCC, suggesting barriers on a multitude of levels.

Although Medicaid Expansion under the Patient Protection and Affordable Care Act (ACA) has been associated with many improvements for patients with cancer, Snyder et al. provide evidence demonstrating the persistence of racial disparities in cancer. This Editorial describes why insurance coverage alone does not ensure access to health care, highlights various manifestations of structural racism that constitute barriers to access beyond the direct costs of care, and calls for not just equality, but equity, in cancer care.

This study evaluates the independent association of Medicaid expansion on stage of presentation among patients of Black and White race with colorectal (CRC), breast, or non-small cell lung cancer (NSCLC).

A cohort study of patients with CRC, breast cancer, or NSCLC (2009-2017) in the National Cancer Database was performed. Difference-in-differences (DID) analysis was used to compare changes in tumor stage at diagnosis between Medicaid expansion (MES) and non-expansion states (non-MES) before and after expansion. Predictive margins were calculated by race, year, and insurance status to account for effect heterogeneity. Stage migration was determined by measuring the combined proportional increase in stage I and decrease in stage IV disease at diagnosis.

Black patients gained less Medicaid coverage than White patients (6.0% vs 13.1%, p < 0.001) after expansion. Among Black and White patients, there was a shift towards increased early-stage diagnosis (DID 3.5% and 3.5%, respectively; p < 0.001) and decreased late-stage diagnosis (DID White: -3.5%; Black -2.5%; p < 0.001) in MES compared to non-MES following expansion. Overall stage migration was greater for White compared to Black patients with CRC (10.3% vs. 5.1%) and NSCLC (8.1% vs. 6.7%) after expansion. Stage migration effects in patients with breast cancer were similar by race (White 4.8% vs. Black 4.5%).

An increased proportion of Black and White patients residing in Medicaid expansion states presented with earlier stage cancer following Medicaid expansion. However, because the proportion of Black patients is higher in non-expansion states, national racial disparities in cancer stage at presentation appear worse following Medicaid expansion.

Cancer displays some of the largest health-equity concerns of all diseases. This paper draws attention to how health economics research can assess strategies to reduce or even eliminate health disparities and provides pivotal examples of existing research as well as areas for future contributions. The paper also highlights critical data limitations that currently restrain the impact health economics research could have. We then explore new areas of inquiry where economic research is sparse but could have an important impact on health equity, particularly in topics involving Medicare and Medicaid policies that expand reimbursement and generosity of coverage. Health economics studies are notably absent from policies and practices surrounding clinical trials, representing an opportunity for future research. We urge health economics researchers to consider experiments, interventions, and assessments through primary data collection; we further encourage the formulation of multidisciplinary teams to ensure that health economics skills are well melded with other areas of expertise. These teams are needed to maximize novelty and rigor of evidence. As policies are promulgated to address disparities in cancer, involvement of economics in a multidisciplinary context can help ensure that these policies do not have unintended impacts that may deepen inequities.

Cancer is the third largest source of spending for Medicaid in the United States. A working group of the American Public Health Association Genomics Forum Policy Committee reviewed 133/149 pieces of literature addressing the impact of Medicaid expansion on cancer screening and genetic testing in underserved groups and the general population. Breast and colorectal cancer screening rates improved during very early Medicaid expansion but displayed mixed improvement thereafter. Breast cancer screening rates have remained steady for Latina Medicaid enrollees; colorectal cancer screening rates have improved for African Americans. Urban areas have benefited more than rural. State programs increasingly cover BRCA1/2 and Lynch syndrome genetic testing, though testing remains underutilized in racial and ethnic groups. While increased federal matching could incentivize more states to engage in Medicaid expansion, steps need to be taken to ensure that they have an adequate distribution of resources to increase screening and testing utilization.

This study examines the association between Medicaid enrollment, including through the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), and distant stage for three screening-amenable cancers: breast, cervical, and colorectal.

We use the Surveillance, Epidemiology, and End Results Cancer Registry linked with Medicaid enrollment data to compare patients who were Medicaid insured with patients who were not Medicaid insured. We estimate the likelihood of distant stage at diagnosis using logistic regression.

Medicaid enrollment following diagnosis was associated with the highest likelihood of distant stage. Medicaid enrollment through NBCCEDP did not mitigate the likelihood of distant stage disease relative to Medicaid enrollment prior to diagnosis. Non-Hispanic Black patients had a greater likelihood of distant stage breast and colorectal cancer. Residing in higher socioeconomic areas was associated with a lower likelihood of distant stage breast cancer.

Medicaid enrollment prior to diagnosis is associated with a lower likelihood of distant stage in screen amenable cancers but does not fully ameliorate disparities.

Our study highlights the importance of health insurance coverage prior to diagnosis and demonstrates that while targeted programs such as the NBCCEDP provide critical access to screening, they are not a substitute for comprehensive insurance coverage.

This study aims to evaluate the trends in the impact of Medicaid expansion on the use of selected recommended clinical preventive services and examine the differences in use by income level over time.

The data were obtained from the 2011-2019 Behavioral Risk Factor Surveillance System and were analyzed in 2021. This study conducted a difference-in-differences analysis of the association between Medicaid expansion and the use of 5 clinical preventive services, including colon/breast/cervical cancer screenings, HIV testing, and influenza vaccination. Annual percentage change was applied to assess the trends in the impact of Medicaid expansion on the use of clinical preventive services.

The use of all the 5 clinical preventive services varied over time. In almost every year, the use of 4 clinical preventive services (all but HIV testing) among Medicaid expansion states was higher than that among the nonexpansion states. People with lower income used 4 clinical preventive services (all but HIV testing) less frequently than those with higher income, regardless of their residence in expansion or nonexpansion groups. Among the lower-income group, the use of 5 clinical preventive services increased after Medicaid expansion almost every year, with the use of colon cancer screening and HIV testing reaching statistical significance and the impact of Medicaid expansion in the use of each clinical preventive service kept stable from 2014 to 2019.

These findings provide evidence that Medicaid expansion may be associated with sustainably increased use of the selected recommended clinical preventive services among the lower-income population and that Medicaid expansion to reduce financial barriers may be an effective strategy to improve population health.

To examine the healthcare utilization and costs associated with colorectal cancer (CRC) screening by colonoscopy, including costs associated with post-endoscopy events, among average-risk adults covered by Medicaid insurance.

This cohort study evaluated a population of adults (ages 50-75 years) with CRC screening between 1/1/2014 and 12/31/2018 (index = earliest test) from the IBM MarketScan Multi-State Medicaid database. Individuals at above-average risk for CRC or with prior CRC screening were excluded. CRC screening was reported by screening type: colonoscopy, fecal immunochemical test [FIT], fecal occult blood test [FOBT], multi-target stool DNA [mt-sDNA]. Frequency and costs of events potentially related to colonoscopy (defined as occurring within 30 days post-endoscopy) were reported overall, by event type, and by individual event.

We identified a total of 13,134 average-risk adults covered by Medicaid insurance who received screening by colonoscopy; 63.6% (8350) had Medicare dual-eligibility while 36.4% (4785) did not have Medicare dual-eligibility. The mean (SD) cost of a colonoscopy procedure was $684 ($907) and mean (SD) out-of-pocket costs were $6 ($132). Serious gastrointestinal (GI) events (perforation and bleeding) were observed in 4.6% of individuals with colonoscopy, 4.3% had other GI events, and 3.0% had an incident cardiovascular/cerebrovascular event. Mean (SD) event-related costs were $1233 ($5784) among individuals with a serious GI event, $747 ($1961) among individuals with other GI events, and $4398 ($19,369) among individuals with a cardiovascular/cerebrovascular event.

This large, claims-based cohort study reports average (SD) out-of-pocket costs for Medicaid beneficiaries at $6 ($132), which could be one factor contributing to the accessibility of CRC screening by colonoscopy. The incidence of events potentially associated with colonoscopy (i.e. within 30 days after the screening) was 3-4%, and the event-related costs were considerable.

The purpose of this study is to determine the association between Medicaid expansion in Louisiana and cancer mortality by race and sex.

Data from the National Vital Statistics System mortality files were used to quantify deaths from cancer between 2010 and 2019 for Louisiana and a sample of states that had yet to adopt the Affordable Care Act's Medicaid expansion as of December 2019. A series of population-weighted comparative interrupted time series models were estimated to determine whether Louisiana's Medicaid expansion was associated with reduced cancer mortality. Analyses were conducted in May 2021-August 2021.

Medicaid expansion was associated with an average of 3.3 (95% CI= -6.4, -0.1; p=0.045) fewer quarterly cancer deaths per 100,000 Black female Louisiana residents and an average of 5.8 (95% CI= -10.4, -1.1; p=0.015) fewer quarterly cancer deaths per 100,000 Black male residents. There were no statistically significant changes in cancer mortality for White people in Louisiana associated with Medicaid expansion. Following expansion, the Black-White mortality gap in cancer deaths declined by approximately 57% for female individuals (4.6-2.0) and 49% for male individuals (10.1-5.2).

Medicaid expansion in Louisiana was associated with a reduction in cancer mortality for Black female and male adults. Estimates of the association between Medicaid expansion and cancer mortality in Louisiana directly relate to the potential impacts for states that have yet to adopt Medicaid expansion under the Affordable Care Act, which are primarily located in the Southern U.S.

Colorectal cancer (CRC) is the third most diagnosed cancer in the USA, and African Americans experience disproportionate CRC diagnosis and mortality. Early detection could reduce CRC incidence and mortality, and reduce CRC health disparities, which may be due in part to lower screening adherence and later stage diagnosis among African Americans compared to whites. Culturally tailored interventions to increase access to and uptake of CRC stool-based tests are one effective strategy to increase benefits of screening among African Americans. The objectives of this study were to obtain feedback from African Americans on CRC educational materials being developed for a subsequent behavioral clinical trial and explore participants' knowledge, attitudes, and beliefs about CRC and CRC screening. Seven focus groups were conducted between February and November 2020. Participants were African Americans recruited through community contacts. Four focus groups were held in-person and three were conducted virtually due to Covid-19 restrictions. Participants ranked CRC educational text messages and provided feedback on a culturally tailored educational brochure. A focus group guide with scripted probes was used to elicit discussion and transcripts were analyzed using traditional content analysis. Forty-two African Americans participated. Four themes were identified from focus group discussions: (1) knowledge, attitudes, and beliefs on CRC and CRC screening; (2) reliable sources of cancer education information; (3) cultural factors affecting perspectives on health; and (4) community insights into cancer education. Participant input on the brochure was incorporated in content creation. Engaging African American community members to qualitatively examine cancer prevention has value in improving implementation strategy and planning for behavioral clinical trials.

This retrospective study of 86 413 patients (40-64 years old) undergoing surgical resection for a new diagnosis of invasive, nonmetastatic colon cancer included in the National Cancer Database (NCDB) from 2010 to 2015 compared overall survival (OS) in MES to NES. Cox proportional hazard models, fit for OS, and propensity score-matching (PSM) analysis were performed.

In this sample, 51 297 cases (59.2%) lived in MES and 35 116 (40.8%) in NES. Medicaid expansion states had earlier pathological stage compared to NES (stage I 25.38% vs 24.17%, stage II 32.93 vs 33.4%, and stage III 41.69 vs 42.43%; P < .001). 5-year OS in MES was higher than NES (79.1% vs 77.3%; P < .001); however, on both multivariable analysis (MVA) and PSM analysis, MES did not have significantly different OS from NES (hazard ratio (HR), .99, 95% confidence interval (CI), .95-1.03; P = .570; HR, .99, 95% CI, .95-1.03; P = .68).

Among NCDB patients with invasive, nonmetastatic colon cancer residing in MES at time of diagnosis was associated with earlier pathological stage. However, on both MVA and PSM analysis, OS was not significantly different in MES vs NES. Research on patient outcomes, such as receipt of guideline concordant care, can further inform the impact of insurance coverage expansion efforts on cancer outcomes.

Treatment with epidermal growth factor receptor monoclonal antibodies extends life for patients with advanced colorectal cancers (CRCs) whose tumors exhibit wild-type KRAS, but KRAS testing may be underused. We studied the role of socioeconomic factors in the application of KRAS testing.

We identified subjects with stage IV colorectal adenocarcinoma diagnosed 2010-2015 in the Surveillance, Epidemiology, and End Results (SEER) database. We used multivariable logistic regression models to evaluate associations between clinical/demographic factors and the rate of KRAS testing. We used multivariable-adjusted Cox proportional hazards models to assess survival.

We identified 37,676 patients with stage IV CRC, 31.1% of whom were tested for KRAS mutations, of those who had documented KRAS testing, 44% were KRAS mutant. Patients were more likely to be tested if they were younger (odds ratio [OR]=5.10 for age 20 to 29 vs. 80+, 95% confidence interval [CI]: 3.99-6.54, P<0.01), diagnosed more recently (OR=1.92 for 2015 vs. 2010, 95% CI: 1.77-2.08, P<0.01), or lived in an area of high median household income (OR=1.24 for median household income of >$69,311 vs. <$49,265, 95% CI: 1.14-1.35, P<0.01). Patients were less likely to be tested if they had Medicaid (OR=0.83, 95% CI: 0.77-0.88, P<0.01) or were unmarried (OR=0.78, 95% CI: 0.75-0.82, P<0.0001). The risk of death was decreased in patients who received KRAS testing (hazard ratio=0.77, 95% CI: 0.75-0.80, P<0.01).

We found a low rate of KRAS testing in CRC patients with those living in low-income areas less likely to be tested, even after controlling for Medicaid insurance. Our study suggests that socioeconomic disparities persist despite Medicaid insurance.

Insurance status has been linked to important differences in cancer treatment and outcomes in the US. With more than 15 million individuals gaining health insurance through Medicaid expansion, there is an increasing need to understand the implications of this policy within the US cancer population. This review provides an overview of the fundamental principles and nuances of Medicaid expansion, as well as the implications for cancer care.

The Patient Protection and Affordable Care Act presented states with an option to expand Medicaid coverage by broadening the eligibility criteria (eg, raising the eligible income level). During the past 10 years, Medicaid expansion has been credited with a 30% reduction in the population of uninsured individuals in the US. Such a significant change in the insurance profile could have important implications for the 1.7 million patients diagnosed with cancer each year, the oncology teams that care for them, and policy makers. However, several factors may complicate efforts to characterize the effect of Medicaid expansion on the US cancer population. Most notably, there is considerable variation among states in terms of whether Medicaid expansion took place, when expansion occurred, eligibility criteria for Medicaid, and coverage types that Medicaid provides. In addition, economic and health policy factors may be intertwined with factors associated with Medicaid expansion. Finally, variability in the manner in which cancer care has been captured and depicted in large databases could affect the interpretation of findings associated with expansion.

The expansion of Medicaid was a historic public policy initiative. To fully leverage this policy to improve oncological care and to maximize learning for subsequent policies, it is critical to understand the effect of Medicaid expansion. This review aims to better prepare investigators and their audiences to fully understand the implications of this important health policy initiative.

Although colorectal cancer (CRC) screening is highly effective, screening rates lag far below recommended levels, particularly for low-income people. The Colorectal Cancer Control Program (CRCCP) funded $100 million in competitively awarded grants to 25 states from 2009-2015 to increase CRC screening rates among low-income, uninsured populations, in part by directly providing and paying for screening services. Using data from the 2001-2015 Behavioral Risk Factor Surveillance System (BRFSS) and a difference-in-differences strategy, we find no effects of CRCCP on the use of relatively cheap fecal occult blood tests (FOBT). We do, however, find that the CRCCP significantly increased the likelihood that uninsured 50-64-year-olds report ever having a relatively expensive endoscopic CRC screening (sigmoidoscopy or colonoscopy) by 2.9 percentage points, or 10.7%. These effects are larger for women, minorities, and individuals who did not undertake other types of preventive care. We do not find that the CRCCP led to significant changes in CRC cancer detection. Our results indicate that the CRCCP was effective at increasing CRC screening rates among the most vulnerable.

Insurance status modifies healthcare access and inequities. The Affordable Care Act expanded Medicaid coverage for people with low incomes in the United States. This study assessed the consequences of this policy change for cancer care after expansion in 2014.

National Cancer Database (NCDB) public benchmark reports were queried for each malignancy in 2013 and 2016. Furthermore, a systematic search [PubMed, Embase, Scopus and Cochrane] was performed. Data on insurance status, access to cancer screening and treatment, and socioeconomic disparities in these metrics was collected.

Two-tailed analysis of the NCDB revealed that 14 out of 18 eligible states had a statistically significant increase in Medicaid-insured patients with cancer after expansion. The average percentage increase was 51 % (13.2-204 %). From the systematic review, 229 studies were identified, 26 met inclusion. All 21 relevant articles reported lower uninsured rates. The average increase of Medicaid-insured patients was 77 % (9.5-230 %) and the average decrease of uninsured rates was 55 % (13.4-73 %). 15 out of 21 articles reported increased access to care. 16 out of 17 articles reported reductions in inequities.

Medicaid expansion in 2014 increased the number of insured patients with cancer. Expansion also improved access to screening and treatment in most oncologic care, and reduced socioeconomic disparities. Further studies evaluating correlative survival outcomes are needed.

This study informs debates on expansion of Medicaid in state governments and electorates in the United States, and on health insurance reform broadly, by providing insight into how health insurance can benefit people with cancer while revealing how less insurance coverage could harm patients with cancer before and after their diagnosis. This study also contributes to discussions of health insurance mandates, subsidized coverage for people with low incomes, and covered healthcare services determinations by public and private health insurance providers in other countries.

Although Medicaid expansion is associated with decreased uninsured rates and earlier cancer diagnoses, no study has demonstrated an association between Medicaid expansion and cancer mortality. Our primary objective was to quantify the relationship between early Medicaid expansion and changes in cancer mortality rates.

We obtained county-level data from the National Center for Health Statistics for adults aged 20-64 years who died from cancer from 2007 to 2009 (preexpansion) and 2012 to 2016 (postexpansion). We compared changes in cancer mortality rates in early Medicaid expansion states (CA, CT, DC, MN, NJ, and WA) vs nonexpansion states through a difference-in-differences analysis using hierarchical Bayesian regression. An exploratory analysis of cancer mortality changes associated with the larger-scale 2014 Medicaid expansions was also performed.

In adjusted difference-in-differences analyses, we observed a statistically significant decrease of 3.07 (95% credible interval = 2.19 to 3.95) cancer deaths per 100 000 in early expansion vs nonexpansion states, which translates to an estimated decrease of 5276 cancer deaths in the early expansion states during the study period. Expansion-associated decreases in cancer mortality were observed for pancreatic cancer. Exploratory analyses of the 2014 Medicaid expansions showed a decrease in pancreatic cancer mortality (-0.18 deaths per 100 000, 95% confidence interval = -0.32 to -0.05) in states that expanded Medicaid by 2014 compared with nonexpansion states.

Early Medicaid expansion was associated with reduced cancer mortality rates, especially for pancreatic cancer, a cancer with short median survival where changes in prognosis would be most visible with limited follow-up.

The Affordable Care Act and subsequent reforms pose tradeoffs for racial-ethnic, rural, and sex-related groups in the United States experiencing disparities in BRCA1/2 genetic counseling and testing and colorectal cancer screening, calling for policy changes.

A working group of the American Public Health Association Genomics Forum Policy Committee engaged in monthly meetings to examine ongoing literature and identify policy alternatives in the coverage of cancer genetic services for marginalized groups. 589 items were collected; 408 examined. Efforts continued from February 2015 through September 2020.

African Americans and Latinos have shown 7-8 % drops in uninsured rates since the Exchanges opened. The ACA has increased BRCA1/2 test availability while several disparities remain, including by sex. Rural testing and screening utilization rates have improved. Medicaid expansion and the inclusion of Medicare in the ACA have resulted in mixed improvements in colorectal cancer screening rates in marginalized groups.

Cancer genetic testing and screening to date have only partially benefited from healthcare reforms. Sensitivity to cost concerns and further monitoring of emerging data are needed. A reduction in disparities depends on the availability of private insurance, Medicaid and Medicare to the marginalized. Attention to value-based design and the way cancer benefits are translated into actual testing and screening are crucial.

The findings suggest the need for further benefits-related health agency interpretation of and amendments to the ACA, continued Medicaid and innovative Medicare expansion, and incorporation of cancer services values-based considerations at several levels, aimed at reducing group disparities.

Background: Medicaid expansion following the 2010 Affordable Care Act has an unknown impact on palliative treatments. Materials & methods: This registry-based study of individuals with metastatic cancer from 2010 to 2016 identified men and women with metastatic cancer in expansion and non-expansion states who received palliative treatments. A mixed effects logistic regression compared trends in expansion and non-expansion states and generated risk-adjusted probabilities or receiving palliative treatments each year. Results: Despite lower baseline use of palliative treatments, the rate of change was more rapid in expansion states (odds ratio [OR]: 1.02; 95% CI: 1.01-1.03; p < 0.001). The adjusted probability of receiving palliative treatments rose from 21.3 to 26.0% in non-expansion states, and from 19.7 to 26.9% in expansion states. Conclusion: Use of palliative treatments among metastatic cancer patients increased from 2010 to 2016 with a significantly greater increase in Medicaid expansion states, even when adjusting for demographic differences between states.

Introduction: Long-standing disparities in colorectal cancer (CRC) outcomes and survival between Whites and Blacks have been observed. A person-centered approach using latent class analysis (LCA) is a novel methodology to assess and address CRC health disparities. LCA can overcome statistical challenges from subgroup analyses that would normally impede variable-centered analyses like regression. Aim was to identify risk profiles and differences in malignant CRC survivorship outcomes. Methods: We conducted an LCA on the Surveillance, Epidemiology, and End Results data from 1975 to 2016 for adults ≥18 (N = 525,245). Sociodemographics used were age, sex/gender, marital status, race, and ethnicity (Hispanic/Latinos) and stage at diagnosis. To select the best fitting model, we employed a comparative approach comparing sample-size adjusted BIC and entropy; which indicates a good separation of classes. Results: A four-class solution with an entropy of 0.72 was identified as: lowest survivorship, medium-low, medium-high, and highest survivorship. The lowest survivorship class (26% of sample) with a mean survival rate of 53 months had the highest conditional probabilities of being 76-85 years-old at diagnosis, female, widowed, and non-Hispanic White, with a high likelihood with localized staging. The highest survivorship class (53% of sample) with a mean survival rate of 92 months had the highest likelihood of being married, male with localized staging, and a high likelihood of being non-Hispanic White. Conclusion: The use of a person-centered measure with population-based cancer registries data can help better detect cancer risk subgroups that may otherwise be overlooked.

Despite national campaigns and other efforts to improve colorectal cancer (CRC) screening, participation rates remain below targets set by expert panels. We hypothesized that availability and practice patterns of healthcare providers may contribute to this gap.

Using data of the Medical Expenditure Panel Survey for the years between 2000 and 2016, we extracted demographic, socioeconomic, and health-related data as well as reported experiences about barriers to care, correlating results with answers about recent participation in colorectal cancer screening. As CRC screening guidelines recommend initiation of testing at age 50, we focused on adults 50 years or older.

We included responses of 163,564 participants for the period studied. There was a significant increase in CRC screening rates over time. Comorbidity burden, poverty, race, and ethnicity independently predicted participation in screening. Lack of insurance coverage and cost of care played an important role as reported barrier. Convenient access to care, represented by availability of appointments beyond typical business hours, and frequency of provider interactions, correlated with higher rates of screening.

Our data show a positive effect of educational efforts and healthcare reform with coverage of screening. Easy and more frequent access to individual providers predicted a higher likelihood of completed screening tests. This finding could translate into more widespread implementation of screening programs, as the increasingly common virtual care delivery offers a new and convenient option to patients.

The Affordable Care Act facilitated improved insurance coverage for states that expanded Medicaid coverage, but the impact on cancer outcomes is unclear. This study compared changes in the diagnosis and management of colon cancer in states that did and did not participate in Medicaid expansion.

Using a quasi-experimental difference-in-differences (DID) approach, we analyzed Medicaid and uninsured patients in the National Cancer Data Base during 2 time periods: pre (2011-2012) and post expansion (2015-2016). Patients in non-expansion states were compared with those in January 2014 expansion states with regard to changes in patient and facility characteristics, cancer staging, treatment decisions, and surgical outcomes.

Along with increased Medicaid coverage (DID = 20.27; p < 0.001), patients in expansion states had an increase in stage I diagnoses (DID = 2.97; p = 0.035), distance traveled (miles, DID = 6.67; p = 0.005), and treatment at integrated network programs (DID = 2.67; p = 0.045). More early-stage patients were treated within 30 days (DID = 7.24; p = 0.035) and more stage IV patients received palliative care (DID = 5.01; p = 0.048). Among surgical patients, Medicaid expansion correlated with fewer urgent cases (< 7 days, DID = -5.88; p = 0.008) and more minimally invasive surgery (DID = 5.00; p = 0.022). There were no observed differences in postoperative outcomes or adjuvant chemotherapy.

Medicaid expansion correlated with earlier diagnosis, enhanced access, and improved surgical care for colon cancer patients. These findings highlight the importance of improving health insurance coverage and can help guide future policy efforts.

Medicaid expansion under the Patient Protection and Affordable Care Act may be associated with increased screening and may improve access to earlier treatment for cancer, but its association with mortality for patients with cancer is uncertain.

To determine whether Medicaid expansion is associated with improved mortality among patients with cancer.

This is a quasi-experimental, difference-in-difference (DID), cross-sectional, population-based study. Patients in the National Cancer Database with breast, lung, or colorectal cancer newly diagnosed from January 1, 2012, to December 31, 2015, were included. Data analysis was performed from January to May 2020.

Living in a state where Medicaid was expanded vs a nonexpansion state.

The main outcome was mortality rate according to whether the patient lived in a state where Medicaid was expanded.

A total of 523 802 patients (385 739 women [73.6%]; mean [SD] age, 54.8 [6.5] years) had a new diagnosis of invasive breast (273 272 patients [52.2%]), colorectal (111 720 patients [21.3%]), or lung (138 810 patients [26.5%]) cancer; 289 330 patients (55.2%) lived in Medicaid expansion states, and 234 472 patients (44.8%) lived in nonexpansion states. After Medicaid expansion, mortality significantly decreased in expansion states (hazard ratio [HR], 0.98; 95% CI, 0.97-0.99; P = .008) but not in nonexpansion states (HR, 1.01; 95% CI, 0.99-1.02; P = .43), resulting in a significant DID (HR, 1.03; 95% CI, 1.01-1.05; P = .01). This difference was seen primarily in patients with nonmetastatic cancer (stages I-III). After adjusting for cancer stage, the mortality improvement in expansion states from the periods before and after expansion was no longer evident (HR, 1.00; 95% CI, 0.98-1.02; P = .94), nor was the difference between expansion vs nonexpansion states (DID HR, 1.00; 95% CI, 0.98-1.02; P = .84).

Among patients with newly diagnosed breast, colorectal, and lung cancer, Medicaid expansion was associated with a decreased hazard of mortality in the postexpansion period, which was mediated by earlier stage of diagnosis.

Access to care varies by sex such that interactions with insurance status result in mixed patterns of preventive services utilization. We examined sex-specific effects of ACA Medicaid expansions on receipt of CRC screening. We used Behavioral Risk Factor Surveillance System data (2008-2016) for adults aged 50-64 years with household income ≤138% of federal poverty level to examine self-reported lifetime use of guideline-recommended CRC screening services overall and by screening modality. We employed difference-in-difference models comparing changes in CRC screening in 20 Medicaid expansion states before and after the ACA to changes in 18 states that did not expand Medicaid during our study period. We divided the expansion period into implementation (2014) and post-expansion (2016) periods to account for possible lagged effects. We observed time-varying effects of Medicaid expansion that revealed relative increases in CRC screening occurring during the post-expansion period. Heterogeneous effects by sex and by screening modality were also observed: there was a significant relative increase of 16.2 percentage points (95% CI [2.2, 30.2]; p-value = 0.023) in lifetime colonoscopy use among women in expansion states relative to non-expansion states in the post-expansion period. There were no significant effects of Medicaid expansion among men. Health insurance expansion had a lagged but significant effect on CRC screening among low-income non-elderly women in Medicaid expansion states, but no effect for men. The observed increase in CRC screening among women suggests that barriers to CRC screening may differ by sex, and tailored interventions to increase CRC screening improve outcomes.