TOPLINE:

State Medicaid expansion was associated with a lower risk for death within 2 years and a higher likelihood of surgical resection among adults with pancreatic cancer. Survival improvements were largest in states that expanded Medicaid earlier — including those expanding around the 2014 Affordable Care Act rollout — but later expansion states also showed improvements compared with nonexpansion states, with benefits emerging several years after expansion. 

METHODOLOGY:

• Early studies have demonstrated that Medicaid expansion can improve insurance coverage among uninsured and help diagnose cancer earlier. However, studies have not examined the impact of Medicaid expansion on survival in pancreatic cancer over different timelines.
• The current observational cohort study analyzed the association between different Medicaid expansion implementation timelines and survival among patients with pancreatic cancer, using data from the Surveillance, Epidemiology, and End Results (SEER) Research Plus database (2006-2019).
• The study included 51,707 patients with pancreatic cancer from 12 states with SEER data and variable Medicaid expansion timelines. Patients were categorized by state Medicaid expansion status as nonexpansion (17% of patients), early expansion in 2011 (63.5%), on-time expansion in 2014 (12.8%), and late expansion in 2017 (6.7%).
• Primary outcome was 2-year all-cause mortality, and secondary outcome was rate of surgical resection; residents of nonexpansion states served as control individuals in all analyses.

TAKEAWAY:

• Medicaid expansion was associated with lower 2-year mortality risk in early expansion states (hazard ratio [HR], 0.91), on-time expansion states (HR, 0.91), and late expansion states (HR, 0.94).
• Survival improvements generally emerged several years after expansion and varied by patient characteristics. For instance, patients with stage II and III disease experienced greater survival improvements than those with stage IV disease (HR, 0.91 for stage II; HR, 0.81 for stage III).
• Medicaid expansion was associated with a higher likelihood of surgical resection (odds ratio, 1.19; P < .001).
• Expansion was associated with reduced geographic disparities in survival for patients in midsized (HR, 0.94; P = .04) and small (HR, 0.88; P = .02) metropolitan counties but did not reduce income-related disparities.

IN PRACTICE:

“Medicaid expansion was associated with improved survival and surgical access for patients with pancreatic cancer, although improvements were delayed and uneven,” the authors concluded. “Persistent income-related disparities highlight the need for additional policies to achieve equitable outcomes.”

SOURCE:

This study, led by Julien T. Hohenleitner, MD, of Northwell Health in New Hyde Park, New York, was published online on March 4 in JAMA Surgery.

LIMITATIONS:

This is a retrospective cohort study, making it vulnerable to selection bias and unable to establish causation. The SEER database has limited patient-specific variables and does not include relevant covariates such as comorbid status, smoking history, or detailed treatment information; chemotherapy receipt is often incompletely coded and may be a potential mediator of survival. The SEER database contains data from only 12 states in the US, limiting the generalizability of the findings to the nation at large. State populations were highly heterogeneous, and although propensity score matching was used to balance groups, differences likely remain. The difference-in-differences model used in the analysis assumes that diagnostic and treatment advances roll out consistently nationwide; however, such developments are not always used uniformly between urban/rural centers and high/low-income areas, providing further opportunities for confounding from rapid treatment advances in pancreatic cancer care.

DISCLOSURES:

Daniel A. King, MD, PhD, disclosed receiving personal fees from AstraZeneca outside the submitted work. No other disclosures were reported by the authors.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.