Influence of Medicaid Expansion on Rural Medicare Beneficiaries Undergoing Colon Cancer-Directed Surgery in the United States

Abstract

Background: The 2010 Affordable Care Act increased access to colon cancer care for millions of non-elderly adults; however, the direct and indirect impact of Medicaid expansion on Medicare beneficiaries with cancer remains less clear, especially for elderly beneficiaries in rural communities.

Methods: Medicare Provider Analysis and Review file was queried for all fee-for-service (FFS) beneficiaries undergoing cancer-directed surgery for colon cancer between 2012 and 2019. Our primary outcomes included 90-day postoperative morbidity, mortality, return to an emergency department, or readmission in the form of an inpatient hospitalization. Multivariable hierarchical logistic regression analyses akin to a difference-in-difference model were performed, allowing the intervention units (US states) to undergo expansion at different times while also controlling for demographic, clinical, and residential geospatial characteristics. Secondary analyses examined for an interaction between rurality and expansion.

Results: Final analysis included 221,814 Medicare beneficiaries who underwent colon cancer-directed surgery between 2012 and 2019. Overall, 141,159 (63.6%) beneficiaries resided in states that adopted expanded Medicaid eligibility. Controlling for confounding factors, Medicaid expansion was not associated with postoperative surgical outcomes, including 90-day morbidity (p = 0.56), mortality (p = 0.30), presentation to an emergency department (p = 0.79), or readmission to an inpatient hospital (p = 0.43). Similarly, analyses evaluating differential association of expansion on rural beneficiaries found no significant differences associated with Medicaid expansion for rural compared with metropolitan beneficiaries.

Conclusions: In these analyses of over 200,000 Medicare beneficiaries across the United States, we found that Medicaid expansion was not associated with any changes in postoperative outcomes for Medicare beneficiaries undergoing colon cancer-directed surgery, either overall or by rural place of residence.