Improving Survival with Medicaid Expansion in Early Hepatocellular Carcinoma: A Step in the Right Direction

Medicaid expansion (ME) has undoubtedly had noticeable effects on access to cancer screening and treatment across several solid organ malignancies. For patients with breast, colon, and lung cancer, findings show that ME is associated with increased cancer screening, earlier detection, lower disease-related mortality, and overall improved access to care.1,2

Access to care is paramount in hepatocellular carcinoma (HCC), the mainstay of treatment is surgical management. Hepatocellular carcinoma represents about 70% to 90% of all primary hepatic malignancies, and patients with HCC face an overall poor prognosis unless the disease is found at early stages when surgical management is possible.3

Evidence suggests that timely receipt of treatment for HCC improves survival, but the effect of increasing access to care via Medicaid expansion on HCC has not been well established.4,5 This is the question that Henrique et al.6 sought to address with their study entitled “The Impact of Medicaid Expansion in Early-Stage Hepatocellular Carcinoma Care.” This retrospective study collected data from the National Cancer Database (NCDB) and identified 19,745 early HCC patients from 2004 to 2017 by American Joint Committee on Cancer (AJCC) staging. Additionally, patients from states that participated in ME were identified, and outcomes from surgical procedures including ablation, resection, and transplantation in HCC were evaluated.6,7

The study identified 61% of the patient population as living in a pre-expansion state, with no differences in surgical treatment between the ME and non-ME expansion states during the pre-expansion period. However, after ME expansion, utilization of resection and transplantation for HCC increased in the ME states versus the non-ME states. The initial analysis demonstrated an increased utilization of surgical treatment in the ME states for early HCC after expansion, but more importantly, the authors found that survival was increased for patients living in the ME states after expansion and that receipt of surgical treatment was independently associated with improved overall survival. Survival was, in fact, higher in the ME states before ME expansion, but this effect was enhanced further after ME expansion.

Additionally, a difference-in-difference (DID) analysis was performed, which is a quasi-experimental approach that compares an outcome before and after a time-point intervention.6,7,8,9 The unadjusted DID analysis showed that the patients in the ME states had higher rates for receipt of surgical treatment than the individuals in the non-ME states, but no differences were found with other insurance statuses.

The Affordable Care Act (ACA) was initially passed into law in 2010, with an aim to expand health care coverage and access, and to allow medical care to be more equitable.10 Medicaid expansion specifically increased patient eligibility, leading to 20 million Americans gaining insurance by liberalizing criteria based on the poverty line.6,10,11 Prior studies regarding ME association with HPB cancers have shown mixed results.8,12,13 The precise effect that Medicaid expansion has had on cancers outcomes, particularly HCC, has remained difficult to gauge.1,2,11 Hepatocellular carcinoma is the third leading cause of cancer-related death worldwide, with a poor prognosis associated with inadequate surveillance, and surveillance rates are currently only about 36% in cirrhotic populations.14

It is clear that receipt of surgical treatment is highly correlated with adequate surveillance, but improving access to surveillance remains a challenge. Similar to the current study, the study by Elshami et al.7 found that 4848 patients from the NCDB were more likely to have a diagnosis of early HCC in ME states versus non-ME states, and that that these patients in ME states were more likely to undergo resection or transplantation. However, Papageorge et al.13 found that ME expansion was not associated with detection of HCC at an earlier stage in a cohort of 19,751 patients identified from the Surveillance, Epidemiology, and End Results (SEER) database.13

In the current study, Henrique et al.6 presented the first data to suggest that survival improved in early HCC after Medicaid expansion. Additionally, the study demonstrated a 28% increase in the likelihood of surgery among uninsured and Medicaid patients after ME.6 The real question that remains is how to identify HCC patients at an early enough stage to influence survival.

The data from Papageorge et al.13 suggest that Medicaid expansion alone is not enough to capture HCC patients in earlier stages of the disease.13 Parikh et al.14 identified possible methods to improve awareness and surveillance, including patient navigation or mailed outreach, and found that only 15.4% of patients were found to be aware of their cirrhosis before diagnosis of their HCC.

Disparities in outcomes for hepatocellular cancer based on socioeconomic status also have been well documented, and it is clear that gaps exist within and outside the reaches of insurance coverage for access to care in early HCC.14,15 In addition to increasing access to care, improvement in public awareness for screening of HCC is essential, particularly in underserved populations, by offering accessible screening programs for at-risk patients, further education of providers, and collaboration with communities to improve outreach to vulnerable populations. Medicaid expansion represents one small step forward toward tackling the multifaceted challenge of addressing inequities of care in HCC.

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