Cancer is among the most common causes of death and most costly diseases in the US, and timely access to high quality treatment is essential for minimizing cancer morbidity and mortality. Insurance coverage is an important determinant of access to care that contributes to documented disparities in outcomes. The Affordable Care Act (ACA) expanded access to insurance for non-elderly adults through subsidized Marketplace coverage and expansion of Medicaid to low-income adults in participating states. There is little evidence regarding the impact of insurance coverage expansions on access to or quality of cancer care. The proposed project will leverage variation in the timing of ACA provisions and changes in coverage under those provisions across geographic areas to estimate the impacts of insurance coverage expansions on cancer treatment. We use population-based data from Pennsylvania ? the largest Medicaid expansion state that did not have extensive coverage for low-income adults prior to the ACA. Data come from the Pennsylvania state- wide cancer registry, along with data from all-payer inpatient, hospital outpatient, and ambulatory surgery center administrative files from the Pennsylvania Health Care Cost Containment Council (PHC4), linked to the registry at the individual level. The sample includes all non-elderly adult cancer patients in the state, with discharge information across all payers, including for uninsured patients. We use a quasi-experimental approach to estimate the effects of both private (Marketplace) and public (Medicaid) expansions on access to and quality of care for patients diagnosed with the four most common cancers (breast, prostate, lung and colorectal). Specifically, we examine the impact of insurance expansions on insurance coverage for cancer patients (Aim 1), access to cancer treatment (Aim 2), and quality of cancer care (Aim 3). We hypothesize that increases in coverage will be associated with shorter time from diagnosis to treatment; higher likelihood of treatment in accredited cancer centers, academic centers, and high-volume hospitals; increased receipt of guideline concordant care; and reductions in hospital readmission. All analysis will be stratified by cancer type, allowing for assessment of differential impacts across cancers, and we will assess the role of insurance coverage in reducing disparities in access for racial/ethnic minorities and rural populations. The project will provide detailed evidence on how the ACA affected insurance coverage, access, and quality of care for cancer patients, including the impact on existing disparities in care for underserved racial/ethnic minority and rural patients. A detailed understanding of the impacts of health insurance coverage expansions on care for cancer (among the most costly and deadly diseases in the US) will inform federal and state policymakers debating health reform proposals, program officials seeking evidence to guide development and implementation of coverage and care delivery policies, and researchers assessing ongoing policy changes and interventions to reduce disparities in cancer care.

Public Health Relevance

Cancer is among the most common causes of death and most costly diseases in the US, and lack of health insurance can limit access to high quality treatment. This project examines the impact of insurance coverage expansions on access to and quality of cancer care, including among racial/ethnic minorities and rural populations. Evidence on the impacts of health insurance coverage expansions will inform policymakers, program officials, and researchers interested in improving access to and reducing disparities in cancer care.

National Institute of Health (NIH)
Agency for Healthcare Research and Quality (AHRQ)
Research Project (R01)
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Healthcare Effectiveness and Outcomes Research (HEOR)
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Hellinger, Fred
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University of Pittsburgh
Public Health & Prev Medicine
Schools of Public Health
United States
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