Impact of Medicaid expansion under the Patient Protection and Affordable Care Act on lung cancer care in the US

Background: Healthcare disparities significantly affect access to care and outcomes in lung cancer patients. The Patient Protection and Affordable Care Act (ACA) Medicaid expansion (ME) was enacted with the aim of improving access to quality and affordable healthcare. This study aims to determine the impact of ME on access to care and outcomes for patients with lung cancer. Methods: We conducted a retrospective analysis of adults (ages 40–64 years) diagnosed with non-small cell lung cancer (NSCLC) in the National Cancer Database between 2009–2019. The study population was divided into a pre-expansion era (A: 2009–2013) and a post-expansion era (B: 2015–2019). The exposure of interest was residence in a state that expanded Medicaid in 2014 (ME) vs. non-expansion (NE). Outcomes were insurance coverage, clinical stage at diagnosis, treatment facility, and survival. Propensity score analysis was used to determine the association between ME and survival. Results: A total of 202,003 patients were included (era B, 51.6%). The median age was 58 years, the majority of patients were male (53.0%), White (79.7%), had no comorbidities (62.0%) and adenocarcinoma (57.4%). From era A to B, insurance coverage increased to 96.7% (+6.6%), stage I disease to 25.3% (+6.5%), and treatment at an academic facility to 43.9% (+3.5%) in the ME group. For the NE group, the increases were up to 88.3% (+4.3%), 21.6% (+4.0%), and 28.6% (+0.2%), respectively. The increase in stage I cancer diagnosis was most noticeable in females. Following risk adjustment, era B was associated with an improvement in survival outcomes irrespective of ME status. Conclusions: Disparities in lung cancer care seem to have improved after ME. Ongoing monitoring is still necessary to confirm the program’s long-term impact on lung cancer survival.