D. Xiao1,2,3, C. Zheng1,2,3, M. Jindal1,2,3, C. Ihemelandu1,2,3, L. Johnson1,2,3, T. DeLeire2,3, N. Shara1,2,3, W. Al-Refaie1,2,3 1MedStar Georgetown University Hospital,Washington, DC, USA 2MedStar Georgetown Surgical Outcomes Research Center,Washington, DC, USA 3Georgetown University Medical Center,Washington, DC, USA
Introduction: Skepticism on Medicaid program’s ability to provide quality care has contributed to the debate on Affordable Care Act’s (ACA) Medicaid expansion. It is unknown whether Medicaid expansion can improve access to high-quality surgical cancer care for poor Americans. To address this gap, we examined the effects of the largest pre-ACA expansion in Medicaid eligibility, which occurred in New York in 2001. We hypothesized that this policy decreased disparity in access to surgical cancer care at high-quality hospitals (HQH) by insurance type and by race.
Methods: We identified 67,685 non-elderly adults 18-64 years old from the 1997-2006 New York State Inpatient Database who underwent one of nine major cancer resections. HQHs were defined as either high-volume hospitals (HVH, assigned yearly as hospitals of highest procedure volumes that treated 1/3 of all patients) or low-mortality hospitals (LMHs), whose observed-to-expected mortality ratio were < 0.7. Analysis examining access to HVH was restricted only to patients of procedures with strong volume-outcome relationship (esophagus, liver, stomach, pancreas, and urinary bladder; N=10,737).
Disparity was defined as the model-adjusted difference in percentage of patients operated at HQH by insurance type (Medicaid/uninsured vs privately insured) or by race (blacks vs whites). Consistent with published literature, we combined Medicaid and uninsured patients to capture changes in access to care due to newly gained Medicaid coverage by an otherwise uninsured patient. Covariates included age, sex, procedure type and emergency admission. Levels of disparity were calculated quarterly for each pair of comparison, then regressed using interrupted time series to evaluate the impact of Medicaid expansion.
Results: Overall, 15.0% of our study cohort were Medicaid/self-pay and 12.1% were blacks. The disparity in access to HVH by insurance type was reduced by 0.61 percentage points per quarter following the expansion (p=0.003) (Figure). Meanwhile, the Medicaid/uninsured beneficiaries had similar access to LMH as the privately insured; no significant change was detected around the expansion. Conversely, racial disparity has increased by 0.86 percentage points per quarter (p<0.001) in access to HVH (Figure) and by 0.48 percentage points per quarter (p=0.005) in access to LMH after the expansion.
Conclusions: The pre-ACA Medicaid expansion reduced the disparity in access to surgical cancer care at HQH by insurance type. However, it was associated with an increased racial gap in access to HQH for surgical cancer care. Further investigations are needed to explore whether Medicaid expansion may aggravate racial disparity in surgical cancer care.
