Impact of the Affordable Care Act on Colorectal Cancer Screening, Incidence, and Survival in Kentucky

Abstract

Background: Kentucky ranks first in the US in cancer incidence and mortality. Compounded by high poverty levels and a high rate of medically uninsured, cancer rates are even worse in Appalachian Kentucky. Being one of the first states to adopt the Affordable Care Act (ACA) Medicaid expansion, insurance coverage markedly increased for Kentucky residents. The purpose of our study was to determine the impact of Medicaid expansion on colorectal cancer (CRC) screening, diagnosis, and survival in Kentucky.

Study design: The Kentucky Cabinet for Health and Family Services and the Kentucky Cancer Registry were queried for individuals (≥20 years old) undergoing CRC screening (per US Preventative Services Task Force) or diagnosed with primary invasive CRC from January 1, 2011 to December 31, 2016. Colorectal cancer screening rates, incidence, and survival were compared before (2011 to 2013) and after (2014 to 2016) ACA implementation.

Results: Colorectal cancer screening was performed in 930,176 individuals, and 11,441 new CRCs were diagnosed from 2011 to 2016. Screening for CRC increased substantially for Medicaid patients after ACA implementation (+230%, p < 0.001), with a higher increase in screening among the Appalachian (+44%) compared with the non-Appalachian (+22%, p < 0.01) population. The incidence of CRC increased after ACA implementation in individuals with Medicaid coverage (+6.7%, p < 0.001). Additionally, the proportion of early stage CRC (stage I/II) increased by 9.3% for Appalachians (p = 0.09), while there was little change for non-Appalachians (-1.5%, p = 0.60). Colorectal cancer survival was improved after ACA implementation (hazard ratio 0.73, p < 0.01), particularly in the Appalachian population with Medicaid coverage.

Conclusions: Implementation of Medicaid expansion led to a significant increase in CRC screening, CRC diagnoses, and overall survival in CRC patients with Medicaid, with an even more profound impact in the Appalachian population.

Figure 1.

Colorectal cancer (CRC) screening by insurance and Appalachian (App) status. Colorectal cancer screening data were obtained from the Kentucky Cabinet for Health and Family Services from January 1, 2011 to December 31, 2016. (A) All screening cases were separated by insurance status depending on pre-Affordable Care Act (ACA) (screening obtained in 2011 to 2013) or post-ACA status (screening obtained in 2013-2016). (B) Patients with Medicaid coverage who received screening were separated by Appalachian and non-Appalachian status and compared pre- and post-ACA implementation.

Figure 2.

Colorectal cancer (CRC) incidence by insurance and Appalachian (App) status. The CRC incidence from January 1, 2011 to December 31, 2016 was obtained from the Kentucky Cancer Registry. Pre-ACA was defined as the time period from 2011 to 2013 while post-ACA was from 2014 to 2016. (A) All cases of CRC were separated out by insurance types and compared before and after ACA implementation. (B) Incidence rates of CRC were compared in all Medicaid patients separated by Appalachian and non-Appalachian status.

Figure 3.

Colorectal cancer (CRC) survival after Affordable Care Act (ACA) by insurance type. Survival analysis was performed via Kaplan-Meier plots. Pre-ACA was defined as the time period between 2011 and 2013, and post-ACA was defined as the time period between 2014 and 2016. All CRC cases were separated by insurance status: (A) private; (B) Medicaid; (C) Medicare; and (D) no insurance.

Figure 4.

Colorectal cancer (CRC) survival for Medicaid patients after Affordable Care Act (ACA) by Appalachian status. Medicaid patients who were diagnosed with CRC were identified in the Kentucky Cancer Registry from January 1, 2011 to December 31, 2016. Survival analysis was performed with Kaplan-Meier plots to evaluate survival in the (A) non-Appalachian and (B) Appalachian population.