Insurance Expansion Improved Care for Colorectal Cancer

The expansion of healthcare in Massachusetts in 2006 was associated with increased rates of resection, and a decreased likelihood of emergent resection, for patients with colorectal cancer, according to the results of a study published in the Journal of Clinical Oncology.

Past research had shown that patients without health insurance typically presented with more advanced colorectal cancer disease and had lower survival rates compared with patients with private insurance. The 2006 Massachusetts health insurance expansion provided Medicaid coverage for people living below 150% of the federal poverty limit, created a state-subsidized insurance program for people with income less than 300% of the federal poverty limit but who remained ineligible for Medicaid, and established an individual mandate requiring all residents to have health insurance.

“Our results suggest that the Massachusetts coverage expansion was independently associated with a 44% increased rate of resection of colorectal cancer in the populations affected most directly by the law,” wrote Andrew P. Loehrer, MD, MPH, of Massachusetts General Hospital in Boston, and colleagues. “The insurance expansion was also associated with an increase in the probability of resection being performed after an elective admission and a decreased probability of resection occurring after emergent admission.”

Loehrer and colleagues used data from the Hospital Cost and Utilization Project State Inpatient Databases to identify 17,499 patients with government-subsidized, self-pay, or private insurance admitted to the hospital between 2001 and 2011 in Massachusetts and compared them with 144,253 control patients from three states.

The comparison showed that prior to the 2006 health insurance reform, those patients with government-subsidized or self-pay insurance had significantly lower rates of resection for colorectal cancer compared with patients with private insurance.

The health insurance reform was independently associated with a 44% increased rate of resection for government-subsidized or self-pay patients (incident rate ratio [IRR], 1.44 [95% CI, 1.23–1.68]; P < .001). More specifically, the reform was associated with a 49% increased rate of resection for colon cancer and a 34% increase in resection for rectal cancer.

“Given the unique aspects of healthcare in the state, our findings in Massachusetts may not be generalizable elsewhere,” the researchers wrote. “However, our evaluation of resection rates and admission types before the reform showed similar trends in both Massachusetts and the control states before implementation. Furthermore, our inclusion of privately insured patients as a separate, intrastate control group still demonstrated significantly increased rates of surgery and a decreased probability of emergent resection for government-subsidized or self-pay patients in Massachusetts after coverage expansion.”

The Massachusetts insurance expansion was also associated with a 6.21 percentage point decreased probability of emergent admission (95% CI, −11.88 to −0.54; P = .032) and an 8.13 percentage point increased probability of an elective admission (95% CI, 1.34–14.91; P = .019) compared with the control states.

The researchers acknowledged that the data are limited “by a lack of clinical granularity, oncologic variables, and long-term survival data. Therefore, we cannot adequately account for stage at time of diagnosis or receipt of stage-appropriate treatment.”