Eliminating Medicaid dental benefits and early-stage oral cancer diagnoses.

BACKGROUND: Despite the importance of regular dental visits for detecting oral cancer, millions of low-income adults lack access to dental services. In July 2009, California eliminated adult Medicaid dental benefits. We tested if this impacted oral cancer detection for Medicaid enrollees. METHODS: We analyzed Surveillance, Epidemiology, and End Results-Medicaid data, which contains verified Medicaid enrollment status, to estimate a difference-in-differences model. Our design compares the change in early-stage (Stages 0-II) diagnoses before and after dropping dental benefits in California with the change in early-stage diagnoses among eight states that did not change Medicaid dental benefits. Patients were grouped by oropharyngeal cancer (OPC) and non-OPC (oral cavity cancer), type, and the length of Medicaid enrollment. We also assessed if the effect of dropping dental benefits varied by the number of dentists per capita. RESULTS: Dropping Medicaid dental benefits was associated with a 6.5%-point decline in early-stage diagnoses of non-OPC (95% CI = -14.5, -3.2, p = 0.008). This represented a 20% relative reduction from baseline rates. The effect was highest among beneficiaries with 3 months of continuous Medicaid enrollment prior to diagnosis who resided in counties with more dentists per capita. Specifically, dropping dental coverage was associated with a 1.25%-point decline in the probability of early-stage non-OPC diagnoses for every additional dentist per 5000 population (p = 0.006). CONCLUSIONS: Eliminating Medicaid dental benefits negatively impacted early detection of cancers of the oral cavity. Continued volatility of Medicaid dental coverage and provider shortages may be further delaying oral cancer diagnoses. Alternative approaches are needed to prevent advanced stage OPC.

Late-Stage Oral Cancer Detection After California and Illinois Restored Medicaid Dental Benefits.

Objective: Previous research found an association between California's Medicaid dental coverage and oral cancer detection. However, this relationship has yet to be explored in other states or by subgroup populations. Study Design: In addition to controlling for sociodemographic and tumor characteristics, this study implemented a traditional difference-in-differences design to compare distant-stage diagnosis trends in states restoring Medicaid dental benefits (California [CA] and Illinois [IL]) with trends in states with constant Medicaid dental benefits. Setting: This retrospective, observational study analyzed oral cavity and pharynx cancer case data from The Surveillance, Epidemiology, and End Results program (2004-2017). Methods: The outcome was a binary variable indicating whether a patient was diagnosed at a distant stage. Subgroup analyses were conducted by state, race/ethnic group, sex, age, and county-level household income. Results: The sample included 109,997 adults diagnosed with cancer of the oral cavity and pharynx. Restoring Medicaid dental benefits was associated with a statistically significant 2.7%-point decline in the probability of a distant-stage oral cancer diagnosis. This estimate represented a 14% relative change from baseline rates. Results were consistent for CA and IL and by county-level median income. Estimates were significantly larger for adults under age 65, males, and adults identifying as Hispanic; non-Hispanic Black; American Indian; or Asian American or Pacific Islander. Conclusion: Restoring Medicaid dental coverage improved early detection in both CA and IL, with the greatest reductions in distant-stage diagnoses occurring in younger adults, males, and minoritized racial/ethnic groups. Future research should investigate whether earlier detection reduces oral cancer mortality disparities.

Head and Neck Cancer Incidence in the United States Before and During the COVID-19 Pandemic.

Importance: Research about population-level changes in the incidence and stage of head and neck cancer (HNC) associated with the COVID-19 pandemic is sparse. Objective: To examine the change in localized vs advanced HNC incidence rates before and during the first year of the pandemic. Design, Setting, and Participants: In this cross-sectional study of patients in the US diagnosed with HNC from 2017 to 2020, the estimated number with cancer of the oral cavity and pharynx (floor of mouth; gum and other mouth; lip; oropharynx and tonsil; and tongue) and larynx were identified from the SEER cancer registry. Subgroup analyses were stratified by race and ethnicity, age, and sex. Data were analyzed after the latest update in April 2023. Exposure: The COVID-19 pandemic in 2020. Main Outcomes and Measures: The primary outcomes were the annual incidence rates per 100 000 people for localized HNC (includes both localized and regional stages) and advanced HNC (distant stage) and weighted average annual percentage change from 2019 to 2020. Secondary outcomes included annual percentage change for 2017 to 2018 and 2018 to 2019, which provided context for comparison. Results: An estimated 21 664 patients (15 341 [71%] male; 10 726 [50%] ≥65 years) were diagnosed with oral cavity and pharynx cancer in 2019 in the US, compared with 20 390 (4355 [70%] male; 10 393 [51%] ≥65 years) in 2020. Overall, the HNC incidence rate per 100 000 people declined from 11.6 cases in 2019 to 10.8 in 2020. The incidence rate of localized cancer declined to 8.8 cases (-7.9% [95% CI, -7.5 to -8.2]) from 2019 to 2020. The localized cancer incidence during the first year of the pandemic decreased the most among male patients (-9.3% [95% CI, -9.2 to -9.5]), Hispanic patients (-12.9% [95% CI, -12.9 to -13.0]), and individuals with larynx cancer (-14.3% [95% CI, -13.6 to -15.0]). No change in the overall incidence rate was found for advanced HNC. Conclusions and Relevance: In this cross-sectional study, the incidence of localized HNC declined during the first year of the pandemic. A subsequent increase in advanced-stage diagnoses may be observed in later years.

Medicaid Expansion Lowered Uninsurance Rates Among Nonelderly Adults In The Most Heavily Redlined Areas.

Medicaid expansion narrowed racial and ethnic disparities in health coverage, but few studies have explored differential impact by exposure to structural racism. We analyzed data on historical residential redlining in US metropolitan areas from the Mapping Inequality project, along with data on uninsurance from the American Community Survey, to test whether Medicaid expansion differentially reduced uninsurance rates among nonelderly adults exposed to historical redlining. Our difference-in-differences analysis compared uninsurance rates in Medicaid expansion and nonexpansion states both before (2009-13) and after (2015-19) the state option to expand Medicaid pursuant to the Affordable Care Act took effect in 2014. We found that Medicaid expansion had the greatest impact on lowering uninsurance rates in census tracts with the highest level of redlining. Within each redline category, there were no significant differences by race and ethnicity. Our results highlight the importance of considering contextual factors, such as structural racism, when evaluating health policies. States that opt not to expand Medicaid delay progress toward health equity in historically redlined communities.

The 2020 US cancer screening deficit and the timing of adults' most recent screen: a population-based cross-sectional study.

OBJECTIVE: In 2020, cancer screenings declined, resulting in a cancer screening deficit. The significance of this deficit, however, has yet to be quantified from a population health perspective. Our study addresses this evidence gap by examining how the pandemic changed the timing of American adults' most recent cancer screen. METHODOLOGY: We obtained population-based, cancer screening data from the Behavioural Risk Factor Surveillance System (BRFSS) (2010, 2012, 2014, 2016, 2018, 2020). Mammograms, pap smears and colonoscopies were each specified as a variable of mutually exclusive categories to indicate the timing since the most recent screening (never, 0-1 years, 1-2 years, 3+ years). Our cross-sectional, quasi-experimental design restricts the sample to adults surveyed in January, February or March. We then leverage a quirk in the BRFSS implementation and consider adults surveyed in the second year of the 2020 survey wave as exposed to the COVID-19 pandemic. Respondents surveyed in January 2020-March 2020 were considered unexposed. To estimate the impact of exposure to the COVID-19 pandemic on the timing of recent cancer screenings, we constructed linear and logistic regression models which control for sociodemographic characteristics associated with screening patterns, and state fixed effects and temporal trend fixed effects to control for confounding. RESULTS: In 2020, the cancer screening deficit was largely due to a 1 year delay among adults who receive annual screening, as the proportion of adults reporting a cancer screen in the past year declined by a nearly identical proportion of adults reporting their most recent cancer screen 1-2 years ago (3%-4% points). However, the relative change was higher for mammograms and pap smears (17%) than colonoscopies (4%). We also found some evidence that the proportion of women reporting never having completed a mammogram declined in 2020, but the mechanisms for this finding should be further explored with the release of future data. CONCLUSION: Our estimates for the pandemic's effect on cancer screening rates are smaller than prior studies. Because we account for temporal trends, we believe prior studies overestimated the effect of the pandemic and underestimated the overall downward trend in cancer screenings across the country leading up to 2020.

Autumn in New York: The case of long-term care facilities in the "Safe Staffing" lawsuit with less staffing but similar COVID-19 outcomes.

BACKGROUND AND OBJECTIVES: In 2022, 239 New York state Long-Term Care Facilities (LTCFs) challenged a "Safe Staffing" law in court. Our study compares LTCFs involved and not involved in the lawsuit, testing for differences in staffing measures and resident outcomes during the first year of the COVID-19 pandemic. RESEARCH DESIGN AND METHODS: New York LTCF level data were obtained from the Centers for Medicare and Medicaid Services 2019 organization and 2020 COVID-19 datafiles. These data were then linked to data from the Long-Term Care Community Coalition, which identified the LTCFs involved in the "Safe Staffing" lawsuit. We first tested for differences in reported 2019 staffing levels by lawsuit involvement. Second, we specified "Doubly Robust" regression models to test if lawsuit involvement was associated with differences in resident COVID-19 infections, COVID-19 deaths, and overall mortality. RESULTS: LTCFs involved in the lawsuit reported lower staff ratings and fewer staffing hours compared to LTCFs not involved in the lawsuit. Despite finding higher rates of admissions with COVID-19 in LTCFs involved in the lawsuit, we did not find that COVID-19 infections, COVID-19 deaths, or overall mortality differed by lawsuit involvement. DISCUSSION AND IMPLICATIONS: LTCFs involved in the lawsuit were deemed by policymakers as reducing staff, earning excess profits, and placing residents at-risk. While these LTCFs reported lower staffing levels, we observed no differences in resident outcomes during the first year of the COVID-19 pandemic. Researchers and policy makers should develop more nuanced perspectives concerning the relationship among LTCF staffing, outcomes, and organizational profitability.

Examining Racial Disparities in Unemployment Among Health Care Workers Before, During, and After the COVID-19 Pandemic.

Among the U.S. health care workforce, the COVID-19 pandemic appeared to greatly impact employment levels in 2020. However, no research has examined how the pandemic's impact on employment varied by racial/ethnic group or beyond the initial emergency year. Our study aimed to quantitatively evaluate workforce trends by race/ethnicity before, during, and after the COVID-19 pandemic. This study analyzed each March supplement of the Current Population Survey over a 5-year span (2018-2022). We restricted the sample to nurses, physician assistants, and other non-physician health care workers (HCW), per specific census occupation codes, and constructed an event-history study to test for differential effects from each year, as compared to 2019, on the proportion of employment between non-Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic Native (American Indian, Alaska Native, Hawaiian Islander), and non-Hispanic Asian HCW. Results suggest that the pandemic's negative impact on the health care workforce disproportionately reduced employment for HCW self-identifying as Black or Indigenous. Rates for other groups increased 2-3 percentage points in 2020 but returned to prepandemic levels by 2022. However, for Black and Native HCW, the change was twice as large in 2021 and remained significantly higher in 2022 for Black HCW, providing more evidence that the burden of the COVID-19 pandemic disproportionately fell on people of color. Future research investigating how employment disruptions impacted the health care workforce and, potentially, health equity remains warranted.

Estimating the Within-Person Change in Dental Service Access Measures during the COVID-19 Pandemic in the United States.

Background: American adults delay dental care more than any other healthcare service. Unfortunately, the COVID-19 pandemic may have stalled efforts to address dental service delays. Early evidence has suggested substantial declines in dental service visits in the early phase of the pandemic; however, our study is among the first to measure within-person changes from 2019 to 2020 and conduct subgroup analyses to examine if changing dental patterns were mediated by exposure to the pandemic, risk of adverse COVID-19 outcomes, or dental insurance. Methods: We analyzed a National Health Interview Survey panel of individuals initially surveyed in 2019, with subsequent follow-up in 2020. The outcomes included dental service access measures and the interval of a most recent dental visit. By constructing a probability-weighted linear regression model with fixed-effects, we estimated the average within-person change from 2019 to 2020. Robust standard errors were clustered within each respondent. Results: From 2019 to 2020, adults reported a 4.6%-point reduction in the probability of visiting the dentist (p < 0.001). Significantly higher declines were found in Northeast and West regions compared to Midwest and South regions. We find no evidence that declining dental services in 2020 were associated with more chronic diseases, older age, or lack of dental insurance coverage. Adults did not report more financial or nonfinancial access barriers to dental care in 2020 compared to 2019. Conclusions: The long-term effects of the COVID-19 pandemic on delayed dental care warrant continued monitoring as policymakers aim to mitigate the pandemic's negative consequences on oral health equity.

Examining the effect of Medicaid expansion on early detection of head and neck cancer of the oral cavity and pharynx by HPV-type and generosity of dental benefits.

BACKGROUND: Over a decade of evidence supports the claim that increased access to insurance through Medicaid expansions improves early detection of cancer. Yet, evidence linking Medicaid expansions to early detection of head and neck cancers (HNC) of the oral cavity and pharynx, specifically, may be limited by the lack of attention to Human Papillomavirus (HPV) etiology, generosity of dental coverage, and valid inference analyzing state cancer registry data. AIMS: This study reexamined the effect of Medicaid expansion on early detection of HPV+/- HNC in states offering extensive dental benefits. MATERIALS AND METHODS: Specialized data from the Surveillance, Epidemiology, and End Results (SEER) program was analyzed to account for, previously unmeasurable, differential detection patterns of HNCs associated with HPV. Then, to identify the effect of increasing Medicaid eligibility on staging patterns in states offering extensive benefits amidst potentially non-common trends between states, a "Triple Differences" design identifies the differential effect of Medicaid Expansion (with dental coverage) on HPV-negative HNCs relative to the change in HPV-positive HNCs. For valid inference analyzing a small number of state clusters (12) in cancer registry data, each regression model applies a Wild Cluster Bootstrap. RESULTS: Expanding Medicaid eligibility was found to be associated with a decrease in the proportion of distant-stage diagnoses of HPV(-) HNCs, but only among states which increased Medicaid dental generosity at the time of Medicaid expansion. CONCLUSIONS: These results suggest that adding extensive Medicaid dental benefits was the primary mechanism impacting HNC detection. This study highlights the potential positive spillover effects of policies which increase access to public dental coverage for low-income adults, while also showing the limitation of access to dental services for improving early detection of HPV+ HNCs.

Measuring and addressing health equity: an assessment of cancer center designation requirements.

PURPOSE: By requiring specific measures, cancer endorsements (e.g., accreditations, designations, certifications) promote high-quality cancer care. While 'quality' is the defining feature, less is known about how these endorsements consider equity. Given the inequities in access to high-quality cancer care, we assessed the extent to which equity structures, processes, and outcomes were required for cancer center endorsements. METHODS: We performed a content analysis of medical oncology, radiation oncology, surgical oncology, and research hospital endorsements from the American Society of Clinical Oncology (ASCO), American Society of Radiation Oncology (ASTRO), American College of Surgeons Commission on Cancer (CoC), and the National Cancer Institute (NCI), respectively. We analyzed requirements for equity-focused content and compared how each endorsing body included equity as a requirement along three axes: structures, processes, and outcomes. RESULTS: ASCO guidelines centered on processes assessing financial, health literacy, and psychosocial barriers to care. ASTRO guidelines related to language needs and processes to address financial barriers. CoC equity-related guidelines focused on processes addressing financial and psychosocial concerns of survivors, and hospital-identified barriers to care. NCI guidelines considered equity related to cancer disparities research, inclusion of diverse groups in outreach and clinical trials, and diversification of investigators. None of the guidelines explicitly required measures of equitable care delivery or outcomes beyond clinical trial enrollment. CONCLUSION: Overall, equity requirements were limited. Leveraging the influence and infrastructure of cancer quality endorsements could enhance progress toward achieving cancer care equity. We recommend that endorsing organizations 1) require cancer centers to implement processes for measuring and tracking health equity outcomes and 2) engage diverse community stakeholders to develop strategies for addressing discrimination.

Synthesizing 30-years of adult medicaid dental policy research: A scoping review to identify gaps and opportunities.

Objective: Despite the importance of Medicaid for the oral health of low-income adults, the extent to which Medicaid dental policy variation influences outcomes is unknown. This study aims to review the evidence evaluating adult Medicaid dental policies to synthesize conclusions and motivate future research. Data sources: A comprehensive search of academic literature published in English between 1991 and 2020 was conducted to identify studies which evaluated an adult Medicaid dental policy for its effect on outcomes. Studies strictly involving children, policies not related to adult Medicaid dental coverage, and non-evaluation studies were excluded. The data analysis identified the policies, outcomes, methods, populations, and conclusions of the included studies. Results: Among the 2731 unique articles extracted, 53 met the inclusion criteria. 36 studies evaluated the effect of expanding Medicaid dental coverage, which was found to consistently increase dental service visits (21 studies) and reduce unmet dental needs (4 studies). Provider density, reimbursement rates, and level of benefits appear to influence the effect of expanding Medicaid dental coverage. The evidence for changing Medicaid benefits and reimbursement rates were mixed for its impact on provider participation and emergency dental services. Few studies examined how adult Medicaid dental policies impact health outcomes. Conclusions: Most of the recent research has focused on evaluating the effect of expanding or reducing Medicaid dental coverage on dental service utilization. Future research investigating the impact of adult Medicaid dental policies on clinical, health, and wellness outcomes remains warranted. Clinical significance: Low-income adults are responsive to Medicaid dental policy changes and utilize more care with more generous coverage. Less is known about how these policies influence health.

Community socioeconomic status and rural/racial disparities in HPV-/+ head and neck cancer.

Background: Head and Neck Cancer (HNC) is a major cause of cancer morbidity and mortality in the United States, but the burden is not evenly distributed. Rural and racial disparities are obvious across the HNC continuum. Most HNC disparities research have emphasized individual factors perpetuating rural and racial disparities, ignoring the role of community-level factors. Methods: We analyzed data from the Surveillance Epidemiology and End Results (SEER) program's "Specialized HNC-Human Papillomavirus (HPV) Census-Tract SES" datafile (2010-2016). In addition to cancer patient characteristics, this data includes a socioeconomic status (SES) quintile based on the patient's census-tract. Our outcome variables included whether the HNC patient 1) was diagnosed at a distant stage, 2) received initial treatment two or more months after diagnosis, 3) received radiation therapy, 4) survived two years after diagnosis. We tested for differences across SES quintiles, in the full sample and then within rural/racial categories. We then tested for differences between each rural/racial category conditional on SES quintile. Results: For both HPV(-) and HPV + HNCs, patients in higher SES census-tracts have 8-10% lower rates of distant stage diagnoses and delayed treatment initiation, and 12.0-14.5% higher survival rates than patients in lower SES census-tracts. Radiation treatment only varied across SES quintiles in HPV + HNC patients. We find little evidence of rural-urban differences within each socioeconomic quintile. However, within lower SES quintiles, we found significant racial disparities in delayed detection and treatment. These differences were largest in the lowest SES quintile, as non-Hispanic Black patients reported 10-11% higher rates of delayed detection and treatment initiation than non-Hispanic White patients. Conclusions: Our research illustrates the value and constraints in leveraging community-level factors in health disparities research that can ultimately assist in designing effective policies that address and achieve rural and racial cancer equity.

Oral cancer screening prevalence in low-income adults before and after the ACA.

BACKGROUND: Detecting oral cancer early is associated with higher probability of survival, reduced treatment costs, and improved quality of life. Unfortunately, <30% of oral cancers are detected early. Recent health insurance expansions from the Affordable Care Act (ACA) could improve outcomes by increasing access to screening. However, due to the differences in screening practices by physicians and dentists, the impact of expanded access to insurance on oral cancer screenings remains unknown. METHODS: Self-reported oral cancer screening data were obtained from The National Health and Nutrition Examination Survey (NHANES) for years 2011-2017. NHANES questionnaires ask respondents if they have received an oral cancer screen from a physician or dentist in the past year. Along with adjusting for demographic characteristics, this study accounts for unobserved heterogeneity by comparing "Differences-in-Differences" estimates of low-income adults (<200 % FPL) with high-income adults, before and after the ACA (2014), for adults most exposed (<age 65) to insurance expansion. RESULTS: Before and after the ACA, low-income adults had the lowest prevalence of oral cancer screenings. However, relative to high-income adults, the ACA was associated with a 5-6%-point increase in oral cancer screenings for low-income adults under age 65, but only for screenings performed by dentists. CONCLUSIONS: Overall, oral cancer screening rates have been declining across the population, but the ACA may have slowed the decline in low-income adults. Understanding why oral cancer screenings are declining could inform cancer control policies. Research evaluating the impact of access to oral cancer screenings remains warranted.

Impact of Medicaid dental coverage expansion on self-reported tooth loss in low-income adults.

BACKGROUND: Low-income adults delay oral health care due to cost more than any other health care service. These delays lead to caries, periodontal disease, and tooth loss. Expanding Medicaid dental coverage has increased dental visits, but the potential impact on previously unmet oral health needs is not well understood. METHODS: In this analysis, the authors estimated the association between Medicaid dental expansion and tooth loss. Data on self-reported tooth loss among adults below 138% federal poverty guideline were obtained from the Behavioral Risk Factor Surveillance System. A difference-in-differences regression was estimated. Additional analyses stratified according to age and separated extensive and limited dental benefits. RESULTS: Expanding Medicaid dental coverage is associated with increased probability of total tooth loss of 1 percentage point in the total sample, representing a 20% relative increase from the pre-expansion rate. This increase was concentrated in states offering extensive dental benefits and was largest (2.5-percentage-point greater likelihood) among adults aged 55 through 64 years for whom both extensive and limited dental benefits were associated with total tooth loss. CONCLUSIONS: Medicaid expansion with extensive dental benefits was associated with increased total tooth loss among low-income adults. This finding suggests that greater access to oral health care addressed previously unmet oral health needs for this population. PRACTICAL IMPLICATIONS: As public dental coverage continues to expand, dental care professionals may find themselves treating a greater number of patients with substantial, previously unmet, oral health needs. Additional research to understand the long-term effects of Medicaid dental insurance for adults on their oral health is needed.

The Effects of ACA Medicaid Expansions on Health After 5 Years.

We examine the Affordable Care Act Medicaid expansion effects on self-rated health status over 5 years. The study uses data from the Behavioral Risk Factor Surveillance System for 2011-2018 and a difference-in-differences design. There is improvement in health status on a 1 to 5 point scale from poor to excellent health among individuals below 100% of the federal poverty line by 0.031, 0.068, 0.031, 0.064, and 0.087 points in 2014, 2015, 2016, 2017, and 2018, respectively. Changes in 2015, 2017, and 2018 are statistically significant (p < .05), and the 2014 change is marginally significant. The difference between 2014 and 2018 effects is statistically significant (p < .05). In most years, we cannot distinguish changes in days not in good physical or mental health from no effect. Overall, there is only minimal evidence for effects intensifying over time, suggesting that health gains thus far have mostly occurred early on due to unmet needs among those previously uninsured.

Evaluating the Effect of Medicaid Expansion on Black/White Breast Cancer Mortality Disparities: A Difference-in-Difference Analysis.

PURPOSE: Medicaid expansion was designed to increase access to health care. Evidence is mixed, but theory and empirical data suggest that lower cost of care through greater access to insurance increases health care utilization and possibly improves the health of poor and sick populations. However, this major health policy has yet to be thoroughly investigated for its effect on health disparities. The current study is motivated by one of today's most stark inequalities: the disparity in breast cancer mortality rates between Black and White women. METHODS: This analysis used a difference-in-difference fixed effects regression model to evaluate the impact of Medicaid expansion on the disparity between Black and White breast cancer mortality rates. State-level breast cancer mortality data were obtained from the Centers for Disease Control and Prevention. Each state's Medicaid expansion status was provided by a Kaiser Family Foundation white paper. Two tests were conducted, one compared all expanding states with all nonexpanding states, and the second compared all expanding states with nonexpanding states that voted to expand-but did not by 2014. The difference-in-difference regression models considered the year 2014 a washout period and compared 2012 and 2013 (pretreatment) with 2015 and 2016 (posttreatment). RESULTS: Medicaid expansion did not lower the disparity in breast cancer mortality. In contrast to expectations, the Black/White mortality ratio increased in states expanding Medicaid for all Medicaid-eligible age groups, with significant effects in younger age groups (P = .01 to .15). CONCLUSION: These results suggest that states cannot solely rely on access to insurance to alleviate disparities in cancer or other chronic conditions. More exploration of the impacts of low-quality health systems is warranted.