1Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH.
2Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH.
J Natl Compr Canc Netw. 2024 Mar 19;22(3):e237104. doi: 10.6004/jnccn.2023.7104.
The objective of this study was to evaluate the impact of Medicaid expansion on breast cancer treatment and survival among Medicaid-insured women in Ohio, accounting for the timing of enrollment in Medicaid relative to their cancer diagnosis and post-expansion heterogeneous Medicaid eligibility criteria, thus addressing important limitations in previous studies.
Using 2011-2017 Ohio Cancer Incidence Surveillance System data linked with Medicaid claims data, we identified women aged 18 to 64 years diagnosed with local-stage or regional-stage breast cancer (n=876 and n=1,957 pre-expansion and post-expansion, respectively). We accounted for women's timing of enrollment in Medicaid relative to their cancer diagnosis, and flagged women post-expansion as Affordable Care Act (ACA) versus non-ACA, based on their income eligibility threshold. Study outcomes included standard treatment based on cancer stage and receipt of lumpectomy, mastectomy, chemotherapy, radiation, hormonal treatment, and/or treatment for HER2-positive tumors; time to treatment initiation (TTI); and overall survival. We conducted multivariable robust Poisson and Cox proportional hazards regression analysis to evaluate the independent associations between Medicaid expansion and our outcomes of interest, adjusting for patient-level and area-level characteristics.
Receipt of standard treatment increased from 52.6% pre-expansion to 61.0% post-expansion (63.0% and 59.9% post-expansion in the ACA and non-ACA groups, respectively). Adjusting for potential confounders, including timing of enrollment in Medicaid, being diagnosed in the post-expansion period was associated with a higher probability of receiving standard treatment (adjusted risk ratio, 1.14 [95% CI, 1.06-1.22]) and shorter TTI (adjusted hazard ratio, 1.14 [95% CI, 1.04-1.24]), but not with survival benefits (adjusted hazard ratio, 1.00 [0.80-1.26]).
Medicaid expansion in Ohio was associated with improvements in receipt of standard treatment of breast cancer and shorter TTI but not with improved survival outcomes. Future studies should elucidate the mechanisms at play.
本研究旨在评估俄亥俄州医疗补助计划（Medicaid）扩面政策对参保女性乳腺癌治疗和生存的影响，同时考虑到参保时间与癌症诊断的关系以及扩面后 Medicaid 的异质资格标准，从而解决了先前研究中的重要局限性。
利用 2011-2017 年俄亥俄州癌症发病率监测系统（Ohio Cancer Incidence Surveillance System）数据与 Medicaid 理赔数据进行关联，我们确定了 18-64 岁患有局部或区域乳腺癌的女性（分别为 876 名和 1957 名，扩张前和扩张后）。我们考虑了女性参保时间与癌症诊断的关系，并根据收入资格门槛，将扩张后女性标记为符合平价医疗法案（Affordable Care Act，ACA）或不符合 ACA。研究结果包括基于癌症分期的标准治疗方法以及接受保乳术、乳房切除术、化疗、放疗、激素治疗和/或 HER2 阳性肿瘤治疗的情况；治疗开始时间（time to treatment initiation，TTI）；以及总体生存率。我们进行了多变量稳健泊松和 Cox 比例风险回归分析，以评估 Medicaid 扩面与我们感兴趣的结果之间的独立关联，同时调整了患者层面和地区层面的特征。
从扩面前的 52.6%增加到扩面后的 61.0%（ACA 和非 ACA 组分别为 63.0%和 59.9%）。调整潜在混杂因素后，包括 Medicaid 参保时间，诊断在扩面后时期与接受标准治疗的可能性更高相关（调整后的风险比为 1.14 [95%置信区间，1.06-1.22]）和较短的 TTI（调整后的危险比为 1.14 [95%置信区间，1.04-1.24]），但与生存获益无关（调整后的危险比为 1.00 [0.80-1.26]）。
俄亥俄州的 Medicaid 扩面政策与乳腺癌标准治疗的接受率提高和 TTI 缩短有关，但与生存结果的改善无关。未来的研究应阐明发挥作用的机制。
