title: Did Pre-Affordable Care Act Medicaid Expansion Increase Access to Surgical Cancer Care?
abstract: BACKGROUND
  Although the Affordable Care Act (ACA) expanded Medicaid access, it is unknown whether this has led to greater access to complex surgical care. Evidence on the effect of Medicaid expansion on access to surgical cancer care, a proxy for complex care, is sparse. Using New York's 2001 statewide Medicaid expansion as a natural experiment, we investigated how expansion affected use of surgical cancer care among beneficiaries overall and among racial minorities.
  
  
  METHODS
  From the New York State Inpatient Database (1997 to 2006), we identified 67,685 nonelderly adults (18 to 64 years of age) who underwent cancer surgery. Estimated effects of 2001 Medicaid expansion on access were measured on payer mix, overall use of surgical cancer care, and percent use by racial/ethnic minorities. Measures were calculated quarterly, adjusted for covariates when appropriate, and then analyzed using interrupted time series.
  
  
  RESULTS
  The proportion of cancer operations paid by Medicaid increased from 8.9% to 15.1% in the 5 years after the expansion. The percentage of uninsured patients dropped by 21.3% immediately after the expansion (p = 0.01). Although the expansion was associated with a 24-case/year increase in the net Medicaid case volume (p < 0.0001), the overall all-payer net case volume remained unchanged. In addition, the adjusted percentage of ethnic minorities among Medicaid recipients of cancer surgery was unaffected by the expansion.
  
  
  CONCLUSIONS
  Pre-ACA Medicaid expansion did not increase the overall use or change the racial composition of beneficiaries of surgical cancer care. However, it successfully shifted the financial burden away from patient/hospital to Medicaid. These results might suggest similar effects in the post-ACA Medicaid expansion.
authors.affiliation: MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; MedStar Health Research Institute, Washington, DC; Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC. Electronic address: wba6@georgetown.edu.
authors.forename: Waddah B
authors.initials: WB
authors.lastname: Al-Refaie
authors.affiliation: MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; Department of Biostatistics, Bioinformatics, and Biomathematics, Georgetown University, Washington, DC.
authors.forename: Chaoyi
authors.initials: C
authors.lastname: Zheng
authors.affiliation: MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC.
authors.forename: Manila
authors.initials: M
authors.lastname: Jindal
authors.affiliation: MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; MedStar Health Research Institute, Washington, DC; Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC.
authors.forename: Michele Lee
authors.initials: ML
authors.lastname: Clements
authors.affiliation: MedStar Health, Columbia, MD.
authors.forename: Patryce
authors.initials: P
authors.lastname: Toye
authors.affiliation: Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC.
authors.forename: Lynt B
authors.initials: LB
authors.lastname: Johnson
authors.affiliation: MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC.
authors.forename: David
authors.initials: D
authors.lastname: Xiao
authors.affiliation: Georgetown Law and The O'Neill Institute for National and Global Law, Georgetown University, Washington, DC.
authors.forename: Timothy
authors.initials: T
authors.lastname: Westmoreland
authors.affiliation: Georgetown McCourt School of Public Policy, Washington, DC.
authors.forename: Thomas
authors.initials: T
authors.lastname: DeLeire
authors.affiliation: MedStar Health Research Institute, Washington, DC; Georgetown-Howard Universities Center for Clinical and Translational Science, Washington, DC.
authors.forename: Nawar
authors.initials: N
authors.lastname: Shara
mesh_terms: D000328:Adult; D005006:Ethnicity; D005260:Female; D006297:Health Services Accessibility / Q000191:economics / Q000331:legislation & jurisprudence* / Q000706:statistics & numerical data / Q000639:trends; D054625:Healthcare Disparities / Q000191:economics / Q000208:ethnology* / Q000706:statistics & numerical data / Q000639:trends; D006801:Humans; D008297:Male; D008484:Medicaid / Q000331:legislation & jurisprudence*; D017057:Medically Uninsured / Q000706:statistics & numerical data; D008875:Middle Aged; D008913:Minority Groups; D009369:Neoplasms / Q000191:economics / Q000601:surgery*; D009518:New York; D058991:Patient Protection and Affordable Care Act; D012189:Retrospective Studies; D013514:Surgical Procedures, Operative / Q000191:economics / Q000706:statistics & numerical data* / Q000639:trends; D014481:United States