18. Impact of Medicaid Expansion under the Patient Protection and Affordable Care Act on Lung Cancer Care in the US

Objectives. Healthcare disparities affect access to care and outcomes in lung cancer patients. The Affordable Care Act's (ACA) Medicaid expansion was implemented in 2014 with the aim of improving access to healthcare. We sought to determine the impact of Medicaid expansion on access to care and outcomes for patients with lung cancer.

Methods. This retrospective cohort study was performed using the National Cancer Database. All adults (ages 40 – 64 years) diagnosed with non-small cell lung cancer (NSCLC) between 2009 and 2019 were included. The study population was divided into a pre- (A: 2009 – 2011) and post-expansion era (B: 2015 – 2019). The exposure of interest was residence in a state that expanded Medicaid in 2014 – Medicaid expansion (ME) vs. Non-expansion (NE). Outcomes were insurance coverage, lung cancer clinical stage, treatment facility, and survival. Survival analysis and multivariable Cox regression were used to elucidate associations. A p-value <0.05 was deemed statistically significant.

Results. A total of 161,713 patients were included (era A – 36%, and era B – 64%). The mean age was 57 years, and the majority of patients were Caucasian (80%), had no comorbidities (62%) and adenocarcinoma as underlying histology (58%). There was no significant age difference between patients in the ME and NE groups in eras A and B (p>0.05 for both). From era A to B, insurance coverage increased from 90.1% to 96.7% (+6.6%), clinical stage I disease increased from 20.6% to 27.3% (+6.7%), and treatment at an academic facility increased from 39.3% to 43.9% (+4.6) in the ME group. For the NE group, the trends were 84.6% to 88.3% (+3.7%), 18.9% to 23.4% (+4.5%), and 27.8% to 28.6% (+0.8%), respectively. On univariate analysis, ME was associated with a decreased risk of mortality when compared to NE in eras A and B (p <0.05 for both). Following risk adjustment, ME remained an independent predictor for survival only in era B (HR for mortality: 0.96, CI: 0.94 – 0.98; p=0.0009).

Conclusions. The ACA ME is associated with improved insurance coverage and more frequent lung cancer treatment at academic facilities. A higher proportion of early-stage NSCLC and better survival are observed in states that implemented ME. Ongoing monitoring is necessary to confirm the program's long-term impact on access to care and survival for NSCLC.

Aitua Salami (1), Jeremiah Martin (2), Shivam Joshi (3), Emanuela Taioli (3), Cherie Erkmen (4), Sakib Adnan (5), Charles Bakhos (4), (1) University of Minnesota, United States, (2) Southern Ohio Medical Center, Portsmouth, OH, (3) Icahn School of Medicine, New York, NY, (4) Temple University Hospital, Philadelphia, PA, (5) Albert Einstein Medical Center, United States

Loretta Erhunmwunsee

Invited Discussant

Loretta Erhunmwunsee, M.D., F.A.C.S., joined City of Hope in 2015 and is an assistant professor in both the division of thoracic surgery and the division of health equity. Dr. Erhunmwunsee graduated Phi Beta Kappa from Emory University in Atlanta, GA and received her medical doctorate from Harvard Medical School in Boston, graduating magna cum laude.  She continued her post-graduate training at Duke University Medical Center in Durham, NC, completing a general and cardiothoracic surgery residency. Board-certified in both general and thoracic surgery, she became a fellow of the American College of Surgeons in 2018.

Dr. Erhunmwunsee is also a funded health equity researcher who focuses on the impact of social determinants and structural inequities on lung cancer risk, biology and screening. She is the recipient of the 2021 Lung Cancer Research Foundation William C. Rippe Award for Distinguished Research in Lung Cancer. She was also awarded the City of Hope Songs of Hope Beverly and Ben Horowitz Legacy Award in 2021. In 2022, she was invited to participate in the National Lung Cancer Roundtable forum on Lung Cancer Screening and is a member of their Health Equity Task Force. She has written numerous publications and given several local and national presentations that bring awareness to the impact of structural inequities on disparate health outcomes. Additionally, she is a Carol Emmott Foundation 2023 fellow.

Dr. Erhunmwunsee is also highly involved in Diversity, Equity and Inclusion efforts both at COH and nationally. She sits on the COH DE&I Governance Council as well as co-leads the Health Equity in Diverse Populations Workstream at COH. She is also the Vice Chair of the NCCN DEI Director’s Forum and has been a member of the Diversity and Inclusion Workforce of the Society of Thoracic Surgeons since 2019.

Aitua Salami

Abstract Presenter

Aitua is a cardiothoracic surgery fellow at the University of Minnesota. He is interested in all aspects of general thoracic surgery and adult cardiac surgery. 

Specialties: Thoracic, Anatomy and Conditions, Lung--Cancer, Treatment/Procedure/Operation/Surgery, Lung--Cancer