A study published in the JAMA Otolaryngology-Head & Neck Surgery examines the effect of Medicaid expansion on head and neck cancer patients, finding that the expansions under the Affordable Care Act (ACA) were associated with improved access to care for these patients and selective Medicaid expansion may worsen existing regional disparities in terms of access to care and outcomes.
Medicaid expansion refers to a provision in the ACA that called for expansion of Medicaid eligibility to cover more low-income Americans. It was determined that each state would decide whether to participate in the expansion - accept federal funds - or not. As of 2020, 37 states including the District of Columbia accepted Medicaid expansion. South Carolina is one of 14 states that has not. As a result, there are gaps in coverage for adults who have incomes above Medicaid eligibility limits yet still below the poverty level, exacerbating challenges with access to care, which is vital in the early detection of cancer.
We performed the study because delivering timely head and neck cancer care is critical for optimal outcomes."
Evan Graboyes, M.D., a researcher at Hollings Cancer Center at the Medical University of South Carolina and senior author on the study
The surgeon at MUSC Health specializes in the treatment of head and neck cancers.
The team analyzed data from a national sample of nearly 91,000 adults with newly diagnosed head and neck cancer who were identified from the National Cancer Database. In this observational study, researchers examined the effect that Medicaid expansion, as part of the ACA, had on the patients' stages of cancer at the time of diagnosis as well as treatment delays for these patients.
Medicaid expansions are known to increase the percentage of patients getting treatment who have localized (stages I or II) cancer at diagnosis for cancers such as colon and breast cancer that have screening tests. Graboyes said the researchers wanted to know the effect of Medicaid expansions on head and neck cancer, which lacks a screening test, he said.
The study showed in states that expanded Medicaid as part of the ACA, patients with head and neck cancer were more likely to be diagnosed with localized (stages I to II) cancer and initiate treatment in a timelier fashion than patients in nonexpansion states. Because of the strong association with a particular stage at diagnosis and the timely treatment that leads to survival for head and neck cancer, the study suggests that Medicaid expansion that offers insurance coverage may help to improve outcomes for these patients.
"I hope that the data we produce gets referenced and is used by policy makers in the future," Graboyes said.
Helmneh Sineshaw, M.D., lead author on the study and a principal scientist at the American Cancer Society, said the study found that Medicaid expansion provided a huge benefit to those who didn't have access to insurance, leading to earlier diagnosis and timely treatment.
"What we find is that patients, in states that expanded Medicaid, had a greater chance of being diagnosed early, whereas patients living in nonexpansion states were likely to be diagnosed in a more advanced stage," Sineshaw said.
Graboyes said delays in the delivery of head and neck cancers are a key driver of suboptimal survival for patients with head and neck cancers and contribute to racial disparities in mortality. Head and neck cancers are rising in number and carry a high mortality rate, with black patients even more likely to die from it.
This study adds to a growing portfolio of other health disparity studies by Graboyes and colleagues, including:
A 5-year $1.2 million grant from the National Cancer Institute awarded in 2019 to decrease mortality and racial disparities in survival for head and neck cancer patients by developing innovative interventions to improve the timeliness, equity and quality of care delivery.
A 2018 study in JAMA Otolaryngology-Head & Neck Surgery that found that ensuring head and neck cancer patients receive postoperative radiotherapy within six weeks of their surgical procedure maximizes their chances of a cure.
Graboyes said more research is needed to understand more fully how changes in insurance coverage affects patients with head and neck cancer. Although there is a strong relationship between the patient's stage at diagnosis and timely treatment, the current study does not address whether Medicaid expansion is associated with fewer recurrences or better survival since there has not been enough time since the implementation of Medicaid expansion to answer this question.
Another limitation of the current study is that it did not analyze how Medicaid expansion was associated with changes in the cost of treatment for head and neck cancer patients. More research is needed to understand the relative costs of expansion of Medicaid provisions as compared to the assumed cost savings of catching and treating head and neck cancers in a more localized stage (I to II) versus advanced stages (III to IV), he said.
"The study is an important first step in understanding how insurance coverage affects health care delivery for patients with head and neck cancer, particularly those who, due to lack of insurance coverage, are more likely to present with advanced disease and experience treatment delays."
Sineshaw, H.M., et al. (2020) Association of Medicaid Expansion Under the Affordable Care Act With Stage at Diagnosis and Time to Treatment Initiation for Patients With Head and Neck Squamous Cell Carcinoma. JAMA Otolaryngology - Head & Neck Surgery. doi.org/10.1001/jamaoto.2019.4310.