18. Impact of Medicaid Expansion under the Patient Protection and Affordable Care Act on Lung Cancer Care in the US
City of Hope
Duarte, CA
United States - Contact Me
Loretta Erhunmwunsee, M.D., F.A.C.S., is an associate professor in both the division of thoracic surgery and the division of health equity at City of Hope. Dr. Erhunmwunsee graduated Phi Beta Kappa from Emory University in Atlanta, GA and received her medical doctorate from Harvard Medical School in Boston, graduating magna cum laude. She continued her post-graduate training at Duke University Medical Center in Durham, NC, completing a general and cardiothoracic surgery residency. Board-certified in both general and thoracic surgery, she became a fellow of the American College of Surgeons in 2018.
Dr. Erhunmwunsee is also a NCI-funded health equity researcher who focuses on the impact of social determinants and structural inequities on lung cancer risk, biology and screening. Specifically, her research has found that various social and environmental determinants, including PM2.5 and neighborhood deprivation, have significant impact on the rate of aggressive lung tumor mutations and the risk of lung cancer development. She is the recipient of the 2021 Lung Cancer Research Foundation William C. Rippe Award for Distinguished Research in Lung Cancer. She was also awarded the City of Hope Songs of Hope Beverly and Ben Horowitz Legacy Award in 2021.She serves on the National Lung Cancer Roundtable and is a member of their Health Equity Task Force. In 2023, she was named a Carol Emmott Foundation fellow and a Cancer Health 25 – Champions of Health Equity in the Cancer Health Magazine. She also co-led the 2023 NCCN Measuring and Addressing Health-Related Social Needs on Cancer Working Group.
Dr. Erhunmwunsee is also highly involved in Diversity, Equity and Inclusion efforts and serves as the Vice Chair of the NCCN DEI Director’s Forum.
University of Texas Southwestern Medical Center
Dallas, TX
United States - Contact Me
Aitua is a thoracic surgeon with UT Southwestern Medical Center. He is interested in surgical outcomes and health services research.
Description
Methods. This retrospective cohort study was performed using the National Cancer Database. All adults (ages 40 – 64 years) diagnosed with non-small cell lung cancer (NSCLC) between 2009 and 2019 were included. The study population was divided into a pre- (A: 2009 – 2011) and post-expansion era (B: 2015 – 2019). The exposure of interest was residence in a state that expanded Medicaid in 2014 – Medicaid expansion (ME) vs. Non-expansion (NE). Outcomes were insurance coverage, lung cancer clinical stage, treatment facility, and survival. Survival analysis and multivariable Cox regression were used to elucidate associations. A p-value <0.05 was deemed statistically significant.
Results. A total of 161,713 patients were included (era A – 36%, and era B – 64%). The mean age was 57 years, and the majority of patients were Caucasian (80%), had no comorbidities (62%) and adenocarcinoma as underlying histology (58%). There was no significant age difference between patients in the ME and NE groups in eras A and B (p>0.05 for both). From era A to B, insurance coverage increased from 90.1% to 96.7% (+6.6%), clinical stage I disease increased from 20.6% to 27.3% (+6.7%), and treatment at an academic facility increased from 39.3% to 43.9% (+4.6) in the ME group. For the NE group, the trends were 84.6% to 88.3% (+3.7%), 18.9% to 23.4% (+4.5%), and 27.8% to 28.6% (+0.8%), respectively. On univariate analysis, ME was associated with a decreased risk of mortality when compared to NE in eras A and B (p <0.05 for both). Following risk adjustment, ME remained an independent predictor for survival only in era B (HR for mortality: 0.96, CI: 0.94 – 0.98; p=0.0009).
Conclusions. The ACA ME is associated with improved insurance coverage and more frequent lung cancer treatment at academic facilities. A higher proportion of early-stage NSCLC and better survival are observed in states that implemented ME. Ongoing monitoring is necessary to confirm the program's long-term impact on access to care and survival for NSCLC.