Improved Access to Healthcare is Good for Everyone

Abstract

As a community, we strive to make the lives of our patients better. There are enormous research efforts in drug development, outcomes research, and population health. Combine these investigative activities with continuous improvements in clinical care and you have a recipe for quality healthcare that reaches across all aspects of the care delivery continuum. However, for an individual patient to enjoy this improved healthcare, they (usually) need some form of health care funding in the form of insurance (be it private insurance or governmental). Unfortunately, there are too many uninsured people in the US. In 2010, the Affordable Care Act (ACA) attempted to narrow the gap between the insured and uninsured by creating Medicaid Expansion (ME). This resulted in nearly 20 million lowincome people obtaining health coverage via federally supported expansion of Medicaid eligibility on a state-bystate basis. With all these newly funded patients, questions began to arise about the impact of ME on a variety of disease and health processes. Subsequently, the National Cancer Database (NCDB) added a variable in the 2016 Patient Use Data File (PUF), released 2 years ago, denoting whether a patient lived in an ME state or non-ME state. This has allowed for research focused on the effect of expanded health coverage and its association with outcomes for cancer care, including better access to the processes of care. How do we make cancer care better? Some strategies include developing better, less toxic treatments, improving screening for earlier stages of disease, and enhancing access to care. It seems intuitive that reducing the number of uninsured people might increase utilization of medical services by reducing the financial barrier. This, of course, is not a one-to-one relationship, but by providing health coverage for those who have none, we presumably improve affordability of care, thus increasing health care utilization. The Oregon health insurance experiment demonstrated that ME increased health care utilization, as assessed by emergency department use. But what about utilization of surgical care? Work by Al-Refaie et al., using pre-ACA administrative data, would suggest yes. Enhancing access could result in more screening for those cancers where an effective screening program exists (examples include breast and colon cancer). We have seen the impact of expanded healthcare access on cancer screening and the news is good: patients who were previously disadvantaged are now having access to screening mammograms and colonoscopies. This has resulted in a shift towards earlier stages of disease with the expected better survival. But what about cancers that lack meaningful screening programs? Would expanded access to care (and the various processes of oncologic care) have an impact on patients’ lives? In this issue, Fonseca and colleagues looked at data from the NCDB and sought to address this very simple question: what is the impact of ME on pancreatic cancer treatment and outcomes? What they found is important; those patients who lived in states with ME had better utilization of the various processes of care that most experts associate with quality pancreatic cancer care. Patients from ME states were more likely to receive multimodal therapy than those from non-ME states (odds ratio [OR] 1.6). This includes multiagent chemotherapy (OR 1.49), neoadjuvant chemotherapy (OR 1.39), and undergoing resection of their cancer (OR 1.54). These data are compelling and clearly demonstrate the beneficial effect that policy has on healthcare delivery, especially complex oncologic therapy. Furthermore, patients from ME states were more likely to be treated at high-volume centers (OR 1.57). In summary, patients with pancreas cancer in ME states were 50% more Society of Surgical Oncology 2021