Kentucky ranks first in the US in cancer incidence and mortality. Compounded by high poverty levels and a high rate of medically uninsured, cancer rates are even worse in Appalachian Kentucky. Being one of the first states to adopt the Affordable Care Act (ACA) Medicaid expansion, insurance coverage markedly increased for Kentucky residents. The purpose of our study was to determine the impact of Medicaid expansion on colorectal cancer (CRC) screening, diagnosis, and survival in Kentucky.

Study Design

The Kentucky Cabinet for Health and Family Services and the Kentucky Cancer Registry were queried for individuals (≥20 years) undergoing CRC screening (per US Preventative Services Task-Force) or diagnosed with primary invasive CRC from January 1, 2011 to December 31, 2016. CRC screening rates, incidence, and survival were compared before (2011-2013) and after (2014-2016) ACA implementation.


Colorectal cancer screening was performed in 930,176 individuals, and 11,441 new CRCs were diagnosed from 2011 to 2016. Screening for CRC increased substantially for Medicaid patients after ACA implementation (+230%, p < 0.001), with a higher increase in screening among the Appalachian (+44%) compared with the non-Appalachian (+22%, p < 0.01) population. The incidence of CRC increased after ACA implementation in individuals with Medicaid coverage (+6.7%, p < 0.001). Additionally, the proportion of early stage CRC (stage I/II) increased by 9.3% for Appalachians (p = 0.09), while there was little change for non-Appalachians (−1.5%, p = 0.60). Colorectal cancer survival was improved after ACA implementation (hazard ratio 0.73, p < 0.01), particularly in the Appalachian population with Medicaid coverage.


Implementation of Medicaid expansion led to a significant increase in CRC screening, CRC diagnoses, and overall survival in CRC patients with Medicaid, with an even more profound impact in the Appalachian population.

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Publication Date


Notes/Citation Information

Published in Journal of the American College of Surgeons, v. 228, issue 4, p. 342-353.

© 2019 Published by Elsevier Inc. on behalf of the American College of Surgeons

© 2019 This manuscript version is made available under the CC-BY-NC-ND 4.0 license http://creativecommons.org/licenses/by-nc-nd/4.0/

Digital Object Identifier (DOI)


Funding Information

This study was also supported by the Markey Cancer Center Support Grant (NCI P30 CA177558) and T32 NIH Training Grant (T32CA160003). The Center for Clinical and Translational Sciences is funded through the NIH National Center for Advancing Translational Sciences (UL1TR001998).