Implementation of the Patient Protection and Affordable Care Act (PPACA) Affects Treatment Modality in Sinonasal Squamous Cell Carcinoma

Introduction: The treatment of sinonasal squamous cell carcinoma (SNSCC) is complex with several modalities available. With the advent of the Patient Protection and Affordable Care Act (PPACA), the rate of uninsured patients decreased due to Medicaid expansion and the increased availability of private health insurance plans through state-mediated exchanges. However, it remains unknown how these coverage changes have influenced treatment patterns and patient outcomes. We aimed to investigate changes in treatment trends (i.e., surgery with or without adjuvant therapy versus primary medical therapy) and overall survival in the sinonasal squamous cell carcinoma population in the PPACA era.

Methods: The Surveillance, Epidemiology, and End Results (SEER) database was queried for patients with a primary diagnosis of sinonasal squamous cell carcinoma treated between 2008 and 2016 (C30.0, C31.0, C31.1, C31.2, C31.3, C31.8, and C31.9). Information pertaining to Medicaid expansion status at the time of each patient's treatment was extrapolated based on patient year of treatment and the state in which each patient was treated. States represented in the SEER database included California, Connecticut, Michigan, Hawaii, Iowa, New Mexico, Washington, Utah, Georgia, Arkansas, Kentucky, Louisiana, and New Jersey. Utah and Georgia were the only two states not to expand access to Medicaid during the study period. The remaining states expanded access at various points between January 2014 and December 2016. Clinicodemographic information, including disease data, patient age, race, sex, and treatment modality, were collected. Multivariable Cox regression and logistic regression models were fit to identify predictors of overall survival and surgery as the primary treatment modality, respectively.

Results: Of the 4,408 patients included in the study, 680 patients were treated in the Medicaid expansion setting. Medicaid expansion status (OR: 1.63; 95% CI: 1.09–2.45) and private insurance (OR: 2.55 95% CI: 1.53–4.26) were associated with increased likelihood of surgery being offered (with or without adjuvant treatment) as the primary treatment modality, accounting for SNSCC staging, year of diagnosis, race, and patient age as covariates. Neither insurance status nor Medicaid expansion status were associated with improved overall survival in our survival analysis.

Conclusion: The PPACA and related Medicaid expansion were associated with significantly higher odds of surgery being offered (with or without adjuvant therapy) as the primary treatment modality among patients with sinonasal squamous cell carcinoma. The empirical clinical effects of health insurance policy require further investigation in order to inform future informed decisions in this critical legislative realm.

Publication History

Article published online:
12 February 2021