Abstract
Objective
The Affordable Care Act (ACA) of 2010 aimed to improve access to care in the United States by expanding the population eligible for Medicaid coverage and has been associated with decreased rates of uninsurance and increased likelihood of early head and neck cancer diagnosis. This study aims to assess the impact of the ACA and expansion of Medicaid on disease presentation and overall survival for patients with laryngeal carcinoma.
Study Design
Cross‐sectional study.
Setting
Multicenter clinical database.
Methods
Overall survival was assessed with Cox proportional hazard regression analyses for patients diagnosed with laryngeal carcinoma (n = 28,843) between 2004 and 2018 in the National Cancer Database.
Results
The annual prevalence of laryngeal carcinoma significantly increased post‐ACA (2010‐2018) compared to pre‐ACA (2004‐2010) for both non‐expansion (P < .001) and expansion states (P < .001). There was a statistically significant increase in stage IV disease post‐ACA for both non‐expansion states (45.1% post vs 33.1% pre, P < .001) and expansion states (41.8% post vs 32.5% pre, P < .001). There was no significant difference in survival for patients diagnosed with laryngeal cancer post‐ACA (hazard ratio [HR] 0.990, 95% CI 0.933‐1.052) compared to pre‐ACA in non‐expansion states. Expansion states had improved survival post‐ACA (HR 0.904, 95% CI 0.857‐0.954) compared to pre‐ACA.
Conclusion
Increased access to care with the ACA led to increased diagnosis of laryngeal carcinoma and increased diagnosis of late‐stage disease. Although there were significant differences in survival between expansion and non‐expansion states, significant differences in survival outcomes post‐ACA were only noted in expansion states.
Keywords: Affordable Care Act, laryngeal carcinoma, outcomes
Laryngeal cancer is expected to account for 12,650 new cases and 3880 deaths in the United States in 2024, representing 0.6% of all new cancer deaths. 1 Morbidity and mortality of laryngeal cancer remain high, with a 5‐year relative survival rate of 61.5%. 1 Standard treatment modalities for advanced and very advanced laryngeal carcinoma such as chemoradiation, partial and total laryngectomy can have a considerable impact on quality of life, affecting speech, taste, and social‐emotional function. 2 Given the mortality associated with this disease, ease of access to care is of great importance. Insurance status is one aspect of access to care that has been shown to influence stage at diagnosis, time to treatment, and overall survival. 3 , 4 , 5 , 6 , 7 , 8 , 9
A body of evidence has emerged that shows laryngeal carcinoma patients who are uninsured have worse overall outcomes, with one study finding insurance status was the socioeconomic status category most predictive of stage at diagnosis. 10 Disparities in care based on insurance status are especially concerning given that underrepresented groups, which already have poorer outcomes, are overrepresented in the uninsured population. 9 , 10 Interestingly, investigations have found patients with Medicaid also have lower rates of survival compared to and increased treatment delay compared to patients with private forms of insurance (though this may be due to enrollment in Medicaid at the time of diagnosis). 6 , 11 Regardless, insurance status has a significant impact on outcomes in patients with head and neck and specifically laryngeal cancers. 3 , 4 , 5 , 7 , 8
Following the passage of the Patient Protection and Affordable Care Act (ACA) of 2010 and its implementation in 2014, the proportion of uninsured individuals in the population changed substantially. 12 , 13 The ACA aimed to improve access to care in the United States by expanding the population eligible for Medicaid coverage. Its implementation has been associated with decreased rates of noninsurance at presentation and increased likelihood of early head and neck cancer diagnosis. 10 After the 2012 Supreme Court decision in National Federation of Independent Businesses v. Sebelius, individual states were allowed to opt‐in or out of Medicaid expansion, creating a natural experiment between states which expanded Medicaid and those which did not. 14 Studies investigating the ACA's impact on insurance status of patients diagnosed with head and neck cancer have used this fact to investigate the impact of the ACA on rates of insurance. 8 , 10 Although prior investigations have shown that insurance has a significant impact on outcomes in patients with head and neck cancers 10 , 15 and recent studies show decreased rates of uninsurance following passage of the ACA, our study is the first to assess how outcomes for patients with laryngeal carcinoma have changed in expansion and non‐expansion states since the passage of the ACAs. This study aims to be the first to assess the impact of the ACA and expansion of Medicaid on disease presentation and overall survival for patients with laryngeal carcinoma.
Methods
Study Design
This study is a cross‐sectional study of patients with laryngeal carcinoma (n = 28,843) between 2004 and 2018 in the National Cancer Database (NCDB).
The University of Southern California Health Sciences Institutional Review Board approved this study, with waiver of informed consent. The data for this study are derived from a de‐identified NCDB file, released to these investigators under a participant use agreement.
Data Collection and Patient Selection
The data for this study were derived from a de‐identified NCDB file, per the NCDB 2018 Participant Use File. Cases of carcinoma of the larynx were identified using ICD‐10 code C32.0‐C32.3 and C32.8‐C32.9 and histology codes 8010 to 8562 for whom the diagnosis was confirmed microscopically via histology or cytology, with or without immunophenotyping, and for whom clinical or pathologic TNM staging was reported were included. Only patients who had the date of diagnosis, treatment type, as well as order of treatment recorded at the same treating facility were included in the study.
Due to the heterogeneity of treatment modalities for laryngeal carcinoma, clinical staging criteria were utilized. Patients for whom clinical tumor staging was reported per American Joint Commission on Cancer (AJCC) 5th, 6th, or 7th edition staging criteria were only included in the study if their laterality and size of nodal disease was documented such that retroactive staging to the 8th edition AJCC staging criteria could be performed; tumors clinically staged as T4a and T4b were consolidated to T4 stage. Those patients for whom revised 8th edition TNM staging could be performed also underwent retrospective overall stage revisions to stages I to IV per current staging guidelines. Pathologic staging was only available for those patients who underwent definitive surgical resection, and due to a large percentage of patients receiving primary chemotherapy or chemoradiation, statistical analyses were conducted using clinical staging.
Patients were excluded from the study if their state of residence and categorization into a Medicaid expansion group relative to the ACA were missing or undefined. Patients who resided in early adopter states that expanded Medicaid in 2010 were categorized in the pre‐ACA if their year of diagnosis was 2004 to 2009. Those who resided in early adopter states were categorized in the post‐ACA group if their year of diagnosis was 2010 or later. Patients who resided in states that expanded Medicaid in January 2014 or later were categorized as pre‐ACA if their year of diagnosis was 2004 to 2013. Those who resided in these later adopter states were categorized in the post‐ACA group if their year of diagnosis was 2014 or later. Patients who resided in states who elected not to expand Medicaid were categorized as pre‐ACA if their year of diagnosis was 2004 to 2009, and post‐ACA if their year of diagnosis was 2010 or later.
Study Outcome Measures
The primary outcome measure in this study was the association between Medicaid expansion status and all‐cause mortality, stratifying for the date of diagnosis relative to their state of residence and the expansion of the ACA of 2010.
Statistical Analysis
Descriptive statistics for patient demographics and disease presentation was analyzed via chi‐square testing, t tests, and analysis of variance. Stepwise Cox proportional hazards regression analysis was performed to identify significant covariates for survival outcomes and subsequently controlled for on multivariate analysis. Only variables with less than 10% missing covariates were considered for the model. Clinicopathologic features were only incorporated into the analysis if less than 10% of data were absent; a separate distinction was made for nonsurgical patients for whom data were not reported—because of this, lymphovascular invasion was excluded from the model. Variables were entered in the model if significant at an alpha of .25 and remained in the model if significant at an alpha of .10. Survival curves were adjusted for significant covariates identified on multivariate analysis and plotted. Statistical analysis was performed using IBM SPSS 24.3 software (SPSS Inc.).
Results
Figure 1 demonstrates the prevalence of laryngeal carcinoma cases reported to the NCDB between 2004 and 2018. There was a significant difference in mean cases per year between non‐expansion and expansion states (P < .001) both before and after Medicaid expansion. There was a significant increase in the mean cases per year after passage of the ACA of 2010 in both non‐expansion (P < .001) and expansion states (P < .001).
Figure 1.
Prevalence of laryngeal squamous cell carcinoma in the National Cancer Database from 2004 to 2018. ACA, Affordable Care Act.
Table 1 highlights baseline patient demographics in this cross‐sectional analysis of 28,843 patients with laryngeal carcinoma from the NCDB. Most patients were male, non‐Hispanic White, and held public insurance. There was a significant increase in the percentage of patients with public insurance and a decrease in the percentage of patients without insurance after Medicaid expansion in both non‐expansion and expansion states. A greater proportion of patients who lived in non‐expansion states lived in counties where residents were less likely to have high school diplomas (HSD, 35.9% in counties with 17.6% or greater without HSD pre‐ACA, 34.4% post‐ACA, P < .05), whereas a greater proportion of patients in expansion states lived in counties with higher education (20.1% in counties with less than 6.3% without HSD pre‐ACA vs 20.7% post‐ACA). After passage of the ACA, patients in both expansion and non‐expansion states were more likely to have greater comorbidities and higher Charleson‐Deyo score (P < .001).
Table 1.
Patient Demographics for Laryngeal Squamous Cell Carcinoma Patients in the National Cancer Database From 2004 to 2018, Stratified by Medicaid Expansion Status
| Non‐expansion states | Expansion states | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Pre‐ACA | Post‐ACA | Pre‐ACA | Post‐ACA | ||||||||
| Mean | SD | Mean | SD | P‐valuea | Mean | SD | Mean | SD | P‐valueb | P‐valuec | |
| Age | 62.8 | 10.8 | 63.5 | 10.1 | .004 | 63.8 | 10.7 | 64.7 | 10.4 | <.001 | <.001 |
| n | % | n | % | n | % | n | % | ||||
| Sex | <.001 | ||||||||||
| Male | 2852 | 80.8 | 6010 | 80.8 | 8094 | 78.6 | 6085 | 80.4 | |||
| Female | 678 | 19.2 | 1434 | 19.2 | .979 | 2205 | 21.4 | 1487 | 20.7 | .004 | |
| Race | <.001 | ||||||||||
| White | 2737 | 77.5 | 5527 | 74.3 | 8441 | 82.0 | 5991 | 79.1 | |||
| Hispanic | 145 | 4.1 | 400 | 5.4 | 330 | 3.2 | 410 | 5.4 | |||
| API/other | 55 | 1.6 | 144 | 1.9 | 317 | 3.1 | 305 | 4.0 | |||
| Black | 593 | 16.8 | 1371 | 18.4 | <.001 | 1211 | 11.8 | 866 | 11.4 | <.001 | |
| Insurance | <.001 | ||||||||||
| Private | 1117 | 31.6 | 1996 | 26.8 | 3537 | 34.3 | 2300 | 30.4 | |||
| Public | 1901 | 53.9 | 4565 | 61.3 | 6016 | 58.4 | 4999 | 66.0 | |||
| Uninsured/unknown | 512 | 14.5 | 881 | 11.8 | <.001 | 746 | 7.2 | 273 | 3.6 | <.001 | |
| Median household income, 2016 | <.001 | ||||||||||
| Less than $40,227 | 1154 | 34.5 | 2247 | 33.9 | 2019 | 21.6 | 1250 | 19.4 | |||
| $40,227‐$50,353 | 969 | 29.0 | 1893 | 28.5 | 2311 | 24.7 | 1411 | 21.8 | |||
| $50,354‐$63,332 | 647 | 19.4 | 1358 | 20.5 | 2252 | 24.1 | 1555 | 24.1 | |||
| $63,332 or more | 573 | 17.1 | 138 | 17.1 | .613 | 2770 | 29.6 | 2242 | 34.7 | <.001 | |
| Education quartiles, 2016 (% high school diploma in county of residence) | <.001 | ||||||||||
| 17.6% or more | 1205 | 35.9 | 2288 | 34.4 | 2002 | 21.3 | 1478 | 22.8 | |||
| 10.9%‐17.5% | 1080 | 32.2 | 2118 | 31.9 | 2866 | 30.5 | 1818 | 28.1 | |||
| 6.3%‐10.8% | 676 | 20.2 | 1373 | 20.7 | 2630 | 28.0 | 1837 | 28.4 | |||
| Less than 6.3% | 391 | 11.7 | 867 | 13.0 | .158 | 1890 | 20.1 | 1343 | 20.7 | .006 | |
| Charlson‐Deyo score (CDS) | <.001 | ||||||||||
| CDS 0 | 2517 | 71.3 | 4919 | 66.1 | 6949 | 67.5 | 4971 | 65.6 | |||
| CDS 1 | 734 | 20.8 | 1780 | 23.9 | 2470 | 24.0 | 1672 | 22.1 | |||
| CDS 2 | 209 | 5.9 | 494 | 6.6 | 658 | 6.4 | 560 | 7.4 | |||
| CDS 3 | 70 | 2.0 | 249 | 3.3 | <.001 | 222 | 2.2 | 369 | 4.9 | <.001 | |
Abbreviations: ACA, Affordable Care Act of 2010; API, Asian Pacific Islander.
P‐value compares pre‐ACA and post‐ACA subgroups in the non‐expansion states cohort.
P‐value compares pre‐ACA and post‐ACA subgroups in the expansion states cohort.
P‐value compares the non‐expansion state versus the expansion state cohorts.
Table 2 demonstrates differences in disease presentation stratified by race at the time of diagnosis. There were significant differences in severity of disease presentation at time of diagnosis for tumor burden (P < .001), locoregional metastatic disease (P < .001), and distant metastatic disease (P < .001). In non‐expansion states, there was a significant increase in advanced tumor stage (T4, 24.2%‐35.1%, P < .05), nodal stage (N2, 9.5%‐11.2%, P < .05), and overall disease stage (stage IV, 33.1%‐45.1%, P < .01) after passage of the ACA. In expansion states, similar findings were noted after passage of the ACA: There was an increase in advanced tumor stage (T4, 23.3%‐32.3%, P < .001), nodal stage (N2, 9.8%‐11.0%, P = .017), distant metastases (M1, 2.4%‐3.3%, P < .001), and overall disease stage (stage IV, 32.5%‐41.8%, P < .001).
Table 2.
Disease Presentation at Time of Diagnosis for Laryngeal Squamous Cell Carcinoma Patients in the National Cancer Database From 2004 to 2018, Stratified by Medicaid Expansion Status
| Non‐expansion states | Expansion states | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Pre‐ACA | Post‐ACA | Pre‐ACA | Post‐ACA | ||||||||
| n | % | n | % | P‐valuea | n | % | n | % | P‐valueb | P‐valuec | |
| AJCC 8th edition clinical staging | |||||||||||
| T‐stage | <.001 | ||||||||||
| T1 | 1165 | 33.0 | 2150 | 28.9 | 3719 | 36.1 | 2667 | 35.2 | |||
| T2 | 691 | 19.6 | 1122 | 15.1 | 1908 | 18.5 | 1028 | 13.6 | |||
| T3 | 819 | 23.2 | 1555 | 20.9 | 2271 | 22.1 | 1431 | 18.9 | |||
| T4 | 855 | 24.2 | 2615 | 35.1 | <.001 | 2401 | 23.3 | 2446 | 32.3 | <.001 | |
| N‐stage | .006 | ||||||||||
| N0/X | 2864 | 81.1 | 5856 | 78.7 | 8274 | 80.3 | 6018 | 79.5 | |||
| N1 | 288 | 8.2 | 676 | 9.1 | 909 | 8.8 | 625 | 8.3 | |||
| N2 | 336 | 9.5 | 834 | 11.2 | 1010 | 9.8 | 834 | 11.0 | |||
| N3 | 42 | 1.2 | 76 | 1.0 | .011 | 106 | 1.0 | 95 | 1.3 | .017 | |
| M‐stage | <.001 | ||||||||||
| M0/Mx | 3425 | 97.0 | 7178 | 96.5 | 10053 | 97.6 | 7319 | 96.7 | |||
| M1 | 105 | 3.0 | 264 | 3.5 | .120 | 246 | 2.4 | 253 | 3.3 | <.001 | |
| AJCC stage | <.001 | ||||||||||
| I | 1140 | 32.3 | 2114 | 28.4 | 3497 | 34.0 | 2558 | 33.8 | |||
| II | 526 | 14.9 | 788 | 10.6 | 1506 | 14.6 | 800 | 10.6 | |||
| III | 696 | 19.7 | 1187 | 16.0 | 1946 | 18.9 | 1051 | 13.9 | |||
| IV | 1167 | 33.1 | 3353 | 45.1 | <.001 | 3350 | 32.5 | 3163 | 41.8 | <.001 | |
| Clinicopathologic features | |||||||||||
| Grade | <.001 | ||||||||||
| Well differentiated | 478 | 13.5 | 807 | 10.8 | 1331 | 12.9 | 811 | 10.7 | |||
| Moderately differentiated | 1846 | 52.3 | 3576 | 48.1 | 5323 | 51.7 | 3308 | 43.7 | |||
| Poorly differentiated | 689 | 19.5 | 1346 | 18.1 | 2076 | 20.2 | 1416 | 18.7 | |||
| Anaplastic | 10 | 0.3 | 24 | 0.3 | 48 | 0.5 | 40 | 0.5 | |||
| Unknown/no surgery | 507 | 14.4 | 1689 | 22.7 | <.001 | 1521 | 14.8 | 1997 | 26.4 | <.001 | |
| Margins | <.001 | ||||||||||
| Negative | 1967 | 55.7 | 4793 | 64.4 | 6032 | 58.6 | 5014 | 66.2 | |||
| Not evaluated/no surgery | 1222 | 34.6 | 1757 | 23.6 | 3174 | 30.8 | 1617 | 21.4 | |||
| Positive | 342 | 9.7 | 892 | 12.0 | <.001 | 1093 | 10.6 | 941 | 12.4 | <.001 | |
| Lymphovascular invasion | <.001 | ||||||||||
| Absent | 0 | 6158 | 82.7 | 3561 | 34.6 | 6118 | 80.8 | ||||
| Present | 0 | 1283 | 17.2 | 723 | 7.0 | 1453 | 19.2 | ||||
| Not evaluated/no surgery | 3530 | 1 | 0.0 | <.001 | 6015 | 58.4 | 1 | 0.0% | <.001 | ||
| Extracapsular extension | <.001 | ||||||||||
| Absent | 109 | 3.1 | 3228 | 43.3 | 1747 | 17.0 | 3401 | 44.9 | |||
| Present | 10 | 0.3 | 838 | 11.3 | 495 | 4.8 | 890 | 11.8 | |||
| Not evaluated/no surgery | 3411 | 96.6 | 3376 | 45.4 | <.001 | 8057 | 78.2 | 3281 | 43.3 | <.001 | |
Abbreviations: ACA, Affordable Care Act of 2010; AJCC, American Joint Commission on Cancer.
P‐value comparing pre‐ACA and post‐ACA subgroups in the non‐expansion states cohort.
P‐value comparing pre‐ACA and post‐ACA subgroups in the expansion states cohort.
P‐value comparing the non‐expansion state versus the expansion state cohorts.
A stepwise Cox proportional hazard regression analysis was performed to evaluate the impact of the ACA on risk of all‐cause mortality in the context of other relevant covariates and is presented in Table 3. On univariate analysis, several demographic factors including age, sex, race, insurance payor, facility type, comorbidity status (Charlson‐Deyo score), and date of diagnosis relative to ACA expansion status were found to be significant contributors to all‐cause mortality. Clinicopathologic features of grade, stage, and margin status were significant contributors. In the multivariate model, the ACA had a significant impact on the survival of patients in expansion states (P < .001). Patients in non‐expansion states did not demonstrate significantly improved survival post‐ACA (hazard ratio [HR] 0.990, 95% CI 0.933‐1.052) compared to the pre‐ACA, non‐expansion cohort. For patients in expansion states, post‐ACA patients had significantly improved survival (HR 0.904, 95% CI 0.857‐0.954) compared to pre‐ACA patients. The differences in cumulative survival, as stratified by time of diagnosis in relation to passage of the ACA, and Medicaid expansion status are presented in Figure 2.
Table 3.
Multivariate Cox Proportional Hazard Regression Analysis for Risk Factors for All‐Cause Mortality in Laryngeal Squamous Cell Carcinoma
| Exp(B) | 95.0% CI for Exp(B) | Sig. | ||
|---|---|---|---|---|
| Demographics | ||||
| Age at diagnosis | 1.029 | 1.027 | 1.031 | <.001 |
| Sex | ||||
| Male | Ref | |||
| Female | 0.911 | 0.871 | 0.952 | <.001 |
| Race | <.001 | |||
| White | Ref | |||
| Hispanic | 0.693 | 0.628 | 0.765 | <.001 |
| API/other/unknown | 0.736 | 0.652 | 0.831 | <.001 |
| Black | 0.986 | 0.937 | 1.038 | 0.597 |
| Insurance | <.001 | |||
| Private | Ref | |||
| Public | 1.337 | 1.279 | 1.399 | <.001 |
| Uninsured/unknown | 1.166 | 1.086 | 1.252 | <.001 |
| Education quartiles 2016 | <.001 | |||
| 17.6% or more | Ref | |||
| 10.9%‐17.5% | 0.991 | 0.946 | 1.038 | 0.712 |
| 6.3%‐10.8% | 0.942 | 0.896 | 0.991 | 0.021 |
| Less than 6.3% | 0.87 | 0.82 | 0.922 | <.001 |
| Charlson‐Deyo score | <.001 | |||
| CDS0 | Ref | |||
| CDS1 | 1.146 | 1.099 | 1.195 | <.001 |
| CDS2 | 1.373 | 1.285 | 1.466 | <.001 |
| CDS ≥ 3 | 1.797 | 1.633 | 1.978 | <.001 |
| Clinicopathologic features | ||||
| AJCC 8th edition clinical stage | <.001 | |||
| Stage I | Ref | |||
| Stage II | 1.653 | 1.554 | 1.759 | <.001 |
| Stage III | 2.375 | 2.244 | 2.513 | <.001 |
| Stage IV | 3.087 | 2.935 | 3.246 | <.001 |
| Grade | <.001 | |||
| Well differentiated | Ref | |||
| Moderately differentiated | 1.167 | 1.099 | 1.24 | <.001 |
| Poorly differentiated | 1.386 | 1.296 | 1.481 | <.001 |
| Anaplastic | 1.567 | 1.205 | 2.04 | <.001 |
| Unknown | 1.182 | 1.098 | 1.272 | <.001 |
| Surgical margins | <.001 | |||
| Negative | Ref | |||
| Positive | 1.381 | 1.324 | 1.44 | <.001 |
| Unknown | 1.348 | 1.277 | 1.423 | <.001 |
| ACA expansion status | ||||
| Pre‐ACA, non‐expansion | Ref | <.001 | ||
| Post‐ACA, non‐expansion | 0.984 | 0.929 | 1.042 | 0.583 |
| Pre‐ACA, expansion | 0.968 | 0.921 | 1.018 | 0.206 |
| Post‐ACA, expansion | 0.877 | 0.824 | 0.935 | <.001 |
| Expansion states | ||||
| Pre‐ACA | Ref | |||
| Post‐ACA | 0.904 | 0.857 | 0.954 | <.001 |
| Non‐expansion states | ||||
| Pre‐ACA | Ref | |||
| Post‐ACA | 0.99 | 0.933 | 1.052 | 0.753 |
Abbreviations: ACA, Affordable Care Act of 2010; AJCC, American Joint Commission on Cancer; API, Asian Pacific Islander.
Figure 2.
Cumulative survival of patients with laryngeal squamous cell carcinoma in the National Cancer Database from 2004 to 2018, stratified by date of diagnosis relative to passage of the Affordable Care Act (ACA) and Medicaid expansion status with number at risk.
Discussion
Utilizing data from the largest cancer registry in the United States, this study is the first to assess insurance disparities in larynx carcinoma outcomes and the impact of ACA Medicaid expansion using the NCDB. This study of 28,843 patients in the NCDB demonstrated that there was a significant correlation between Medicaid expansion and overall survival rates for patients with laryngeal cancer. These results add to evidence supporting the value of Medicaid expansion by further elucidating its impact on the survival of cancer patients. 16 Insurance status at time of diagnosis has been shown to have a significant impact on outcomes in patients with laryngeal cancer. 5 , 7 The ACA dramatically reduced the uninsured population in the United States and is known to have increased rates of insurance among cancer patients, including those with laryngeal cancer. 10 , 11 , 12 , 13 , 16
Consistent with prior studies, the percentage of uninsured patients with laryngeal cancer decreased, and public insurance increased in both expansion and non‐expansion states after passage of the ACA. 8 , 10 Increases in insurance rates in both expansion and non‐expansion states may be multifactorial in nature due to (1) the effects of the individual mandate requiring that patients have health insurance and (2) the national requirement for the development of statewide marketplaces for individuals to purchase health insurance. These changes likely facilitated increased rates of insurance in both expansion and non‐expansion states. The magnitude of changes in insurance was larger for expansion states, which saw the uninsured patient drop from 7.3% to 3.6%, as opposed to non‐expansion states, which saw a decline from 14.5% to 11.8%
In terms of insurance type, post‐ACA, patients in both expansion and non‐expansion states were more likely to have government insurance than pre‐ACA. Similar to prior studies, our results show that patients with government insurance have poorer survival than other patients, even when compared to uninsured individuals. 5 , 6 , 8 , 17 Regardless, patients in Medicaid expansion states had improved survival outcomes. There are several feasible explanations for this finding. Individuals of higher health literacy, or individuals that would be otherwise considered to be socioeconomically more advantaged, who for different reasons enrolled in Medicaid, may contribute to altered overall survival outcomes. Our study demonstrated that expansion states had a higher proportion of individuals who lived in higher‐educated counties, and health‐literate patients may be more likely to have increased agency in pursuing care, perhaps masking the poorer outcomes of individuals with less health literacy. Expansion likely increases population‐level rates of survival even though Medicaid continues to appear to have poorer overall survival.
Alternatively, Medicaid expansion may also appear to have inferior outcomes in the early years after passage of the legislation. Patients may be enrolling in Medicaid for the first time at the time of diagnosis, leading to more Medicaid patients presenting at later stages, and therefore with a worse prognosis. 5 Other studies have shown poor outcomes for Medicaid patients persist even when controlling for stage at presentation, making this explanation less likely. 5 , 11 Another explanation is that Medicaid patients made up a higher proportion of patients with treatment delay or “at risk of delay” than patients with other insurance types. 4 Regardless of the poorer outcomes reported for Medicaid patients, patients in states that expanded access to Medicaid have, according to our and others' analyses, benefited from expansion. Further research should be conducted to determine what mechanisms are responsible for improved survival outcomes in expansion states, if it is true that Medicaid has inferior outcomes for patients.
Although other cancers have seen an increase in early‐stage diagnosis following passage of the ACA in other cancers, likely due to increased screening, 16 our study identified an increase in the number of late‐stage cancers in both expansion and non‐expansion states following passage of the ACA. One possible explanation is an increased number of Medicaid patients who, in a study by Mehta et al were more likely to be diagnosed with late‐stage laryngeal cancers. Although several studies have noted an association between government insurance and later stage at presentation for laryngeal cancer, 5 , 6 , 11 we postulate that the most likely reason for increased late‐stage cancers is due to increased access to healthcare. Another consideration is that unlike other cancers such as lung, breast, and cervical cancers, there are no gold‐standard screening tests or tools to detect laryngeal and other head and neck cancers, thus resulting in later disease presentation.
Despite this, our analysis of patients in the NCDB showed statistically significant improvement in adjusted survival in Medicaid expansion states without similar findings in non‐expansion states. In Medicaid expansion states, patients with laryngeal cancer had a roughly 10% relative risk reduction in mortality after the ACA. No significant survival benefit was noted in non‐expansion states. This is consistent with a study by Han et al, which showed expansion states had improved survival rates for a variety of cancers both pre‐ and post‐ACA, with statistically significant improvements in overall survival post‐ACA seen only in expansion states. 16 Han et al specifically noted that cancers with poorer outcomes tended to see the greatest improvements following Medicaid expansion. Therefore, similar results between our studies are to be expected.
It should be noted that overall survival was significantly improved in expansion states at baseline prior to the ACA, with a 3.2% relative risk reduction between expansion and non‐expansion states. Expansion states were found to have significantly higher income, level of education, and rates of insurance than non‐expansion states at baseline. The risk reduction seen in expansion states before the ACA may be attributed in part to the prevalence of advantageous sociodemographic factors, which improve outcomes in cancer care at baseline in those states.
Like any cross‐sectional or database study, this study has several limitations. These include the limited utility of the NCDB in evaluating overall disease‐specific survival and recurrence‐free survival, as it does not report disease‐specific mortality and disease recurrence. Additionally, the NCDB is not a nationally representative sample of patients; it only includes hospitals that choose to be accredited by the ACS Commission on Cancer. In the absence of disease‐specific mortality data, it is difficult to attribute the differences in survival solely to disparities in laryngeal cancer treatment. Additionally, our results did not show a significant difference in survival outcomes between historically disadvantaged groups and their white counterparts, as previously reported in other studies, 18 , 19 which may be in part due to a low number of patients included in the study, which may not be adequately powered to detect such differences. Regarding insurance status, the NCDB does not record changes in health insurance, such as if a patient switched insurance or enrolled in Medicaid as a result of the ACA; thus, changes in access to care and subsequent treatment are not reflected in each individual patient record. Furthermore, the NCDB did not require reporting of lymphovascular invasion or extracapsular extension as clinicopathologic risk factors until 2010; thus, absent data in the pre‐ACA group exclude their utility in the overall analysis. It is well documented that extracapsular extension is a significant prognostic factor in laryngeal and head and neck carcinomas, therefore, limiting the generalizability of this study. Lastly, due to the gradual adoption of the ACA between 2010 and 2014, there has been limited time and opportunity to evaluate the impact of increasing healthcare access, especially after an initial period where new enrollees may be diagnosed with later‐stage disease. As such, investigational studies in the future examining the impact of increased healthcare access after the ACA on long‐term survival are certainly warranted.
Conclusion
The ACA has been shown to diminish disparities in insurance of cancer patients in a variety of other cancers, including laryngeal carcinoma. 13 , 16 Increased access to care with the ACA was associated with increased diagnosis of laryngeal carcinoma and increased diagnosis of late‐stage disease. Although there were significant differences in survival between expansion and non‐expansion states, significant differences in survival outcomes post‐ACA were only noted in expansion states. Further work is needed to understand the ACA's long‐term impact on achieving equitable laryngeal cancer care.
Author Contributions
Margaret C. Nurimba, Study design; data analysis/acquisition; drafting and critical revision of manuscript; approval of work to be published. Zachary E. Thompson, Data analysis/acquisition; drafting and critical revision of manuscript; approval of work to be published. Tamara N. Chambers, Study design; drafting and critical revision of manuscript; approval of work to be published. Mark S. Swanson, Study design, drafting and critical revision of manuscript; approval of work to be published.
Disclosures
Competing interests
None.
Funding source
No funding was received in support of this study.
This article was presented at the AAO‐HNSF 2024 Annual Meeting & OTO EXPO; September 28‐October 1, 2024; Miami Beach, Florida.
References
- 1.Cancer of the larynx—cancer stat facts. SEER. Accessed July 28, 2024. https://seer.cancer.gov/statfacts/html/laryn.html
- 2. Braz DSA, Ribas MM, Dedivitis RA, Nishimoto IN, Barros APB. Quality of life and depression in patients undergoing total and partial laryngectomy. Clinics. 2005;60(2):135‐142. 10.1590/s1807-59322005000200010 [DOI] [PubMed] [Google Scholar]
- 3. Cheraghlou S, Kuo P, Judson BL. Treatment delay and facility case volume are associated with survival in early‐stage glottic cancer. Laryngoscope. 2017;127(3):616‐622. 10.1002/lary.26259 [DOI] [PubMed] [Google Scholar]
- 4. Kompelli AR, Li H, Neskey DM. Impact of delay in treatment initiation on overall survival in laryngeal cancers. Otolaryngol Head Neck Surg. 2019;160(4):651‐657. 10.1177/0194599818803330 [DOI] [PubMed] [Google Scholar]
- 5. Mehta V, Shi Z, Mills GM, Nathan CAO, Shi R. Effect of payer status on relative survival of patients with laryngeal cancer. Anticancer Res. 2016;36(1):327‐333. [PubMed] [Google Scholar]
- 6. Chen AY, Schrag NM, Halpern M, Stewart A, Ward EM. Health insurance and stage at diagnosis of laryngeal cancer: does insurance type predict stage at diagnosis? Arch Otolaryngol Head Neck Surg. 2007;133(8):784‐790. 10.1001/archotol.133.8.784 [DOI] [PubMed] [Google Scholar]
- 7. Grewal JS, Law RH, Williams AM, Wertz AG, Chang SS. Does insurance type influence overall survival in patients with laryngeal squamous cell carcinoma? Am J Otolaryngol. 2021;42(4):102959. 10.1016/j.amjoto.2021.102959 [DOI] [PubMed] [Google Scholar]
- 8. Cannon RB, Shepherd HM, McCrary H, et al. Association of the Patient Protection and Affordable Care Act with insurance coverage for head and neck cancer in the SEER database. JAMA Otolaryngol Head Neck Surg. 2018;144(11):1052‐1057. 10.1001/jamaoto.2018.1792 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. Ragin CC, Langevin SM, Marzouk M, Grandis J, Taioli E. Determinants of head and neck cancer survival by race. Head Neck. 2011;33(8):1092‐1098. 10.1002/hed.21584 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Babu A, Wassef DW, Sangal NR, Goldrich D, Baredes S, Park RCW. The Affordable Care Act: implications for underserved populations with head & neck cancer. Am J Otolaryngol. 2020;41(4):102464. 10.1016/j.amjoto.2020.102464 [DOI] [PubMed] [Google Scholar]
- 11. Lebo NL, Khalil D, Balram A, et al. Influence of socioeconomic status on stage at presentation of laryngeal cancer in the United States. Otolaryngol Head Neck Surg. 2019;161(5):800‐806. 10.1177/0194599819856305 [DOI] [PubMed] [Google Scholar]
- 12. Obama B. United States health care reform: progress to date and next steps. JAMA. 2016;316(5):525‐532. 10.1001/jama.2016.9797 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13. Moss HA, Wu J, Kaplan SJ, Zafar SY. The Affordable Care Act's Medicaid expansion and impact along the cancer‐care continuum: a systematic review. JNCI: J Natl Cancer Inst. 2020;112(8):779‐791. 10.1093/jnci/djaa043 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14. Rosenbaum S, Westmoreland TM. The Supreme Court's surprising decision on the Medicaid expansion: how will the federal government and states proceed? Health Aff. 2012;31(8):1663‐1672. 10.1377/hlthaff.2012.0766 [DOI] [PubMed] [Google Scholar]
- 15. Sineshaw HM, Ellis MA, Yabroff KR, et al. Association of Medicaid expansion under the Affordable Care Act with stage at diagnosis and time to treatment initiation for patients with head and neck squamous cell carcinoma. JAMA Otolaryngol Head Neck Surg. 2020;146(3):247‐255. 10.1001/jamaoto.2019.4310 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16. Han X, Zhao J, Yabroff RR, Johnson CJ, Jemal A. Association between Medicaid expansion under the Affordable Care Act and survival among newly diagnosed cancer patients. J Clin Oncol. 2021;39(15_suppl):1502. 10.1200/JCO.2021.39.15_suppl.1502. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17. Kwok J, Langevin SM, Argiris A, Grandis JR, Gooding WE, Taioli E. The impact of health insurance status on the survival of patients with head and neck cancer. Cancer. 2010;116(2):476‐485. 10.1002/cncr.24774 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18. Daraei P, Moore CE. Racial disparity among the head and neck cancer population. J Cancer Educ. 2015;30(3):546‐551. 10.1007/s13187-014-0753-4 [DOI] [PubMed] [Google Scholar]
- 19. Shin J, Truong M. Racial disparities in laryngeal cancer treatment and outcome in the United States: a population‐based SEER analysis of 24,069 patients. Int J Radiat Oncol Biol Phys. 2014;90(1):S535. 10.1016/j.ijrobp.2014.05.1628 [DOI] [Google Scholar]