Impacts of Neighborhood Contexts and Medicaid Policy on Lung Cancer Survival in Low-SES Patients

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PROJECT SUMMARY/ABSTRACT Our prior work showed that Medicaid expansion under the ACA is associated with early detection and improved survival in patients with non-small cell lung cancer, the most common type of lung cancer. However, Medicaid enrollees with lung cancer still have much worse survival compared with their privately insured counterparts, which is driven predominantly by their higher risks of being diagnosed at more advanced stages and under- utilizing stage-appropriate cancer treatment. This suggests that equal healthcare coverage is essential, but insufficient, to ensure equal access to lung cancer care and outcomes. Healthcare access has been conceptualized as a result of the interactions between factors across the individual, provider and healthcare system, neighborhood, and policy levels. However, prior studies addressing lung cancer disparities in low- income patients focused on individual-level factors. We and other groups demonstrated that neighborhood accessibility to cancer care is associated with treatment in patients with breast or colorectal cancer. Medicaid enrollment pre- vs. peri-cancer diagnosis is associated with early-stage cancer diagnoses. Much less is known about the influences of neighborhood contexts, Medicaid enrollment continuation, and Medicaid coverage of lung cancer screening on lung cancer care in Medicaid patients. Tobacco cessation treatment is an integral and essential part of lung cancer treatment. No study has examined the utilization of tobacco treatment and its determinants in low-income lung cancer patients, a medically underserved population with high prevalence of nicotine dependence. We hypothesize that neighborhood contexts, Medicaid policies, and hospitals play critical roles in lung cancer care and survival in Medicaid patients. Employing a robust multilevel modelling approach to account for clustering within providers and neighborhoods, we will assess the impacts of neighborhoods, policies, and hospitals on early detection and oncologic treatment for lung cancer, utilization of tobacco treatment, and lung cancer survival in Medicaid patients, as well as their contributions to racial disparities in lung cancer treatment and survival. To this end, we will develop integrated datasets for Medicaid enrollees diagnosed with lung cancer, which includes nationally representative cancer data, Missouri Medicaid claims and enrollment (also Medicare claims for dual eligible enrollees), Missouri Cancer Registry data, Annual Hospital Surveys, neighborhood contextual measures that we will develop. To our knowledge, this will be the first population-based study to comprehensively assess the contributions of factors at the neighborhood, health policy, and hospital levels to the lung cancer care continuum in low-income patients. The results will help inform interventions by suggesting potentially modifiable factors that could be targeted to improve cancer care in this vulnerable population and thereby reduce lung cancer disparities. Addressing non-financial barriers to cancer care in Medicaid enrollees could maximize the likelihood that substantial investments in Medicaid expansion will translate into true gains in cancer care access and outcomes for low-income patients.