Association for Public Policy Analysis & Management

Breast and colorectal cancers are among the most prevalent forms of cancer in the United States. Breast cancer (BCA) is the second leading cause of cancer death among US women, and colorectal cancer (CRC) is the second leading cause of cancer death overall. There are substantial disparities in BCA and CRC diagnosis, treatment, and outcomes in the US by insurance and socioeconomic status, among other factors. Those who are uninsured or underinsured are significantly more likely to be diagnosed at late stages, less likely to receive recommended treatment, and suffer poorer health outcomes as a consequence. Insurance expansions such as those enacted Affordable Care Act (ACA) could improve diagnosis, treatment, and outcomes among the newly insured. Potential improvements in care and outcomes may take time to manifest as providers adjust to accommodate an influx of new patients and as newly insured patients learn to navigate the healthcare system. Pre-ACA state-level coverage expansions can provide timely evidence of how expansions affect cancer diagnosis and treatment, and where gaps in the system remain.

The 2006 Massachusetts health reform substantially increased coverage in the state. Key provisions of the reform closely parallel those of the ACA, for which Massachusetts served as a model. While there is now a substantial literature examining the effects of the reform, few studies have examined cancer diagnosis and treatment. This study uses the large expansion of health insurance coverage in Massachusetts as a natural experiment to investigate the effect of coverage on BCA and CRC cancer diagnosis and treatment. We use a quasi-experimental framework to assess the effects of insurance expansions in Massachusetts on BCA and CRC diagnosis and treatment. Data come from the Massachusetts Cancer Registry and the National Cancer Institute’s Surveillance Epidemiology and End Results (SEER) cancer registries from other comparison states. We exploit variation across states and across counties within Massachusetts to estimate the relationship between health reform implementation in Massachusetts and diagnosis and treatment outcomes. Results from this research provide timely evidence regarding the effect of insurance expansions under health reform on cancer diagnosis and treatment. The health insurance landscape continues to evolve at both the state and national levels. By providing evidence on the relative importance of insurance coverage versus other factors, the results will help policymakers, providers, and other stakeholders identify where increases in coverage improve diagnosis and quality of care and where gaps remain.