Association of Medicaid expansion with 2‐year survival and time to treatment initiation in gastrointestinal cancer patients: A National Cancer Database study

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Abstract
Introduction: We evaluated whether Medicaid expansion (ME) was associated with improved 2‐year survival and time to treatment initiation (TTI) among patients with gastrointestinal (GI) cancer.Methods: GI cancer patients diagnosed 40–64 years were queried from the National Cancer Database. Those diagnosed from 2010 to 2012 were considered pre‐expansion; those diagnosed from 2014 to 2016 were considered post‐expansion. Cox models estimated hazard ratios and 95% confidence intervals (CIs) for 2‐year overall survival. Generalized estimating equations (GEE) estimated odds ratios (OR) and 95% CI of TTI within 30‐ and 90 days. Multivariable Difference‐in‐Difference models were used to compare expansion/nonexpansion cohorts pre‐/post‐expansion, adjusting for patient, clinical, and hospital factors.Results: 377,063 patients were included. No significant difference in 2‐year survival was demonstrated across ME and non‐ME states overall or in site‐based subgroup analysis. In stage‐based subgroup analysis, 2‐year survival significantly improved among stage II cancer, with an 8% decreased hazard of death at 2 years (0.92; 0.87–0.97). Those with stage IV had a 4% increased hazard of death at 2 years (1.04; 1.01–1.07). Multivariable GEE models showed increased TTI within 30 days (1.12; 1.09–1.16) and 90 days (1.22; 1.17–1.27). Site‐based subgroup analyses indicated increased likelihood of TTI within 30 and 90 days among colon, liver, pancreas, rectum, and stomach cancers, by 30 days for small intestinal cancer, and by 90 days for esophageal cancer. In subgroup analyses, all stages experienced improved odds of TTI within 30 and 90 days.Conclusion: ME was not associated with significant improvement in 2‐year survival for those with GI cancer. Although TTI increased after ME for both cohorts, the 30‐ and 90‐day odds of TTI was higher for those from ME compared with non‐ME states. Our findings add to growing evidence of associations with ME for those diagnosed with GI cancer.

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