Medicaid Expansion and Disparity Reduction in Surgical Cancer Care at High-Quality Hospitals

Abstract

Background: The Affordable Care Act's Medicaid expansion has been heavily debated due to skepticism about Medicaid's ability to provide high-quality care. Particularly, little is known about whether Medicaid expansion improves access to surgical cancer care at high-quality hospitals. To address this question, we examined the effects of the 2001 New York Medicaid expansion, the largest in the pre-Affordable Care Act era, on this disparity measure.

Study design: We identified 67,685 nonelderly adults from the New York State Inpatient Database who underwent select cancer resections. High-quality hospitals were defined as high-volume or low-mortality hospitals. Disparity was defined as model-adjusted difference in percentage of patients receiving operations at high-quality hospitals by insurance type (Medicaid/uninsured vs privately insured) or by race (African American vs white). Levels of disparity were calculated quarterly for each comparison pair and then analyzed using interrupted time series to evaluate the impact of Medicaid expansion.

Results: Disparity in access to high-volume hospitals by insurance type was reduced by 0.97 percentage points per quarter after Medicaid expansion (p < 0.0001). Medicaid/uninsured beneficiaries had similar access to low-mortality hospitals as the privately insured; no significant change was detected around expansion. Conversely, racial disparity increased by 0.87 percentage points per quarter (p < 0.0001) in access to high-volume hospitals and by 0.48 percentage points per quarter (p = 0.005) in access to low-mortality hospitals after Medicaid expansion.

Conclusions: Pre-Affordable Care Act Medicaid expansion reduced the disparity in access to surgical cancer care at high-volume hospitals by payer. However, it was associated with increased racial disparity in access to high-quality hospitals. Addressing racial barriers in access to high-quality hospitals should be prioritized.

Figure 1

Adjusted Level of Disparity by Insurance Type (Difference between Privately Insured and Uninsured/Medicaid) in Access to High Quality Hospitals (HQH) among Recipients of Cancer Surgery in New York State, 1997–2006. Source: State Inpatient Database. Linear trends represent fitted values. HVH, high-volume hospitals; LMH, low-mortality hospitals

Figure 2

Adjusted Level of Racial Disparity (Difference Between African-American and non-Hispanic White Patients) in Access to High Quality Hospitals (HQH) among Recipients of Cancer Surgery in New York State, 1997–2006. Source: State Inpatient Database. Linear trends represent fitted values. HVH, high-volume hospitals; LMH, low-mortality hospitals