The Medicaid Expansion’s Impact on Affordable Care: Did it Increase the Number of Patients Receiving Adjuvant Radiation Treatment?

A recent analysis by Amy Le, MD, and Jordan A. Holmes, MD, MPH, from the Indiana University School of Medicine, Indianapolis, Indiana, investigated the impact that the Affordable Care Act’s expansion of Medicaid had on patients with endometrial cancer. Patients with high-intermediate risk endometrial cancer typically receive adjuvant radiation therapy (RT) for treatment, which has been shown to reduce the chance of disease recurrence. Patients that are treated with external beam RT (EBRT) or vaginal cuff brachytherapy (BT) also have lower chances of getting endometrial cancer for a second time (1.6% vs 1.8%, P = .7). Vaginal cuff BT is typically more convenient for the patient and has a more favorable side effect profile than pelvic EBRT. The American Society for Radiation Oncology (ASTRO) guidelines recommend that patients with grade 1 or 2 endometrial cancers or grade 3 tumors receive adjuvant RT treatment. However, it has been found that a significant number of patients do not get this care despite ASTRO guideline recommendations. 

In 2010, the Patient Protection and Affordable Care Act was passed to improve health care access for patients and expand the insurance options for Medicaid. The Supreme Court ruled that states had the option to implement the new health insurance standards, and many states (Kentucky, Nevada, Colorado, Oregon, New Mexico, West Virginia, Arkansas, Rhode Island, Arizona, Maryland, Massachusetts, North Dakota, Ohio, Iowa, Illinois, Vermont, Hawaii, New York, Delaware, Washington, California, New Jersey, Minnesota, and Connecticut; plus, the District of Columbia) enacted Medicaid expansion. In the states that did not, many patients were left without health insurance coverage.

The goal of Le and Holmes’s study was to investigate the impact of Medicaid expansion on RT treatment for patients diagnosed with endometrial cancer. The researchers’ hypothesis was that in states without Medicaid expansion, there would be fewer patients who received adjuvant RT treatment than in the states with Medicaid expansion.

For this study, the National Cancer Database was used to find patients diagnosed with endometrial adenocarcinoma in stages IA and grade 3 or stage IB and grade 1 or 2 from 2010 to 2018. The patients included in this data were between the ages of 40 and 64 years old. The 24 states (and the District of Columbia) that expanded their Medicaid programs did so on or before January 1, 2014, so Le and Holmes used that date as the beginning of the post expansion period in their study. A sensitivity analysis was performed for patients who underwent EBRT grouped with patients who did not receive any adjuvant treatment, and a difference in differences (DID) cross-sectional analysis was performed to compare the percentage change in patients who received adjuvant RT before and after Medicaid expansion. In nonexpansion and expansion states, patient age, race, insurance status, income quartile, rurality, Charlson-Deyo comorbidity score, lymphovascular space invasion, and receipt of regional nodal surgery were similar. 

In total, 8,847 patients were included in the analysis, with a median age of 59. About half (47.4%) of patients were living in states that had expanded Medicaid, and the other half (52.6%) lived in states that had not. The study found that the number of patients receiving adjuvant BT in nonexpansion states was 2.68% higher than that in expansion states; however, this difference was not statistically significant (P = .236). The sensitivity analysis, which compared patients who received adjuvant EBRT with patients who did not receive any form of adjuvant RT, resulted in similar findings that were not statistically significant. Higher rates of adjuvant BT were seen in expansion states prior to January 2014 compared to nonexpansion states (36.58% vs 26.75%). The number of patients that received adjuvant BT as a part of their care increased over the course of the study period across both groups, with a larger percentage point increase seen in expansion states, although this difference was also not statistically significant (adjusted DID: 0.25 [95% confidence interval: –4.03-4.53]; P = .909).

Le and colleagues concluded that Medicaid expansion is not a major factor affecting health care access or receipt of adjuvant RT for patients with endometrial cancer. “Other contributing factors to disparities in receipt of adjuvant treatment could be socio-economic status, race/ethnicity, education level, comorbid conditions, distance to treatment center, type of treatment center (comprehensive cancer center vs. not comprehensive), and geographic location,” the authors said. They also noted that providing more insurance coverage options can help patients that need access to higher quality care; however, changes from Medicaid to private insurance and vice versa can make it harder to accurately assess the full impact of Medicaid expansion. 

Source:
Le A, Holmes J. Changes in receipt of adjuvant brachytherapy for endometrial cancer patients before and after affordable care act: The impact of Medicaid expansion. J Contemp Brachytherapy. 2023;15(3):206-211. doi:10.5114/jcb.2023.127838.