Affordable Care Act Medicaid Expansion is Associated with Increased Utilization of Minimally Invasive Lung Resection for Early-Stage Lung Cancer
Christine E. Alvarado1, Jonathan D. Rice1, Gianna Dingillo2, Jillian Sinopoli1, Avanti Badrinathan1, Philip A. Linden1, Christopher W. Towe1
1Surgery, University Hospitals Cleveland Medical Center, Shaker Heights, Ohio, United States, 2Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
Objective: Minimally invasive lung resection (MILR) is underutilized in the United States. Under the Affordable Care Act (ACA), 39 states adopted Medicaid expansion, while 12 did not. Although Medicaid expansion has been associated with improved access to cancer care, its effect on utilization of MILR is unclear. We hypothesize that MILR would increase in states that expanded Medicaid.
Methods: The National Cancer Database (NCDB) was queried for adult patients (age 39-64) from 2010-2018 with cT1/2N0M0 non-small cell lung cancer who received surgical resection by wedge, segmentectomy, or lobectomy. Patients were grouped by whether they received care in a state with Medicaid expansion in Jan 2014 or a state that did not expand Medicaid. The outcome of interest was MILR (defined as VATS or robotic) relative to open. We conducted a multivariable difference-indifferences (DID) cross-sectional analysis to estimate the average treatment effect (ATE) of Medicaid expansion.
Results: There were 41,439 patients who met inclusion criteria during the study period: 20,446 (49.3%) in expansion states and 20,993 (50.7%) in non-expansion states. There were several differences between patients based on expansion status including differences in age, sex, histology, and T stage. Notably, Medicaid was more common in expansion states (3,279/24,446 (16.0%) vs 1,902/20,993 (9.1%), p<0.001). Multivariable DID analysis suggested that Medicaid expansion was associated with an increase in Medicaid insurance type with an ATE of 7.4% (95% CI 7.1%-7.7%, p=0.002). Medicaid expansion was also associated with increased MILR use in unadjusted analysis (10,278/20,446 (50.3%) vs 9,953/20,993 (47.4%), p<0.001) and in multivariable DID analysis (ATE 0.6%, 95%CI 0.3%-0.8%, p=0.008). The ATE for MILR utilization among patients without private insurance was 1.4% (95%CI 0.4%-2.4%, p=0.034).
Conclusions: Although Medicaid expansion was associated with increased utilization of MILR for early-stage lung cancer in the NCDB, the treatment effect was modest. This suggests that barriers in access to minimally invasive lung resection are larger than simply access to care. Strategies to increase utilization of MILR may require more radical methods such as regionalization of care.
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