Defense Date


Document Type


Degree Name

Doctor of Philosophy


Healthcare Policy & Research

First Advisor

Lindsay Sabik, PhD

Second Advisor

Cathy Bradley, PhD

Third Advisor

David Harless, PhD

Fourth Advisor

Harry Bear, MD, PhD


Medicaid expansion under the Affordable Care Act (ACA) facilitates access to care among vulnerable populations, but 21 states have not yet expanded the program. Tennessee’s Medicaid program experienced a dramatic Medicaid contraction when the program disenrolled approximately 170,000 nonelderly adults in 2005. Pre-ACA expansions were associated with better access to and utilization of healthcare services. However, little is known about the effect of these policy changes on improvement in health outcomes for women diagnosed with breast cancer, access to care for cancer survivors, and the effect of generosity and duration of expansion on access to care.

This dissertation has three objectives. First, to assess the effects of the Tennesse’s Medicaid disenrollment on stage at diagnosis and delay in surgery for breast cancer among nonelderly women. Second, to compare access to care between cancer survivors living in non-expansion states and survivors living in expansion states. Third, to examine the effect of generosity and duration of the pre-ACA Medicaid expansions on access to and utilization of healthcare services.

I use three different types of datasets: the 2002-2008 data from Tennessee Cancer Registry, the 2012 and 2013 Behavioral Risk Factor Surveillance System (BRFSS), and the 2012 Medical Expenditure Panel Survey (MEPS) data. I estimate difference-in-difference models and perform multiple logistic regression models to examine the impact of these policy changes on the different measurement outcomes.

While many states are expanding Medicaid eligibility under the Affordable Care Act, there has been discussion among policymakers in some states about reducing eligibility under the Affordable Care Act once full federal funding expires. This study suggests that Medicaid disenrollment leads to later stage at diagnosis for breast cancer patients, indicating negative health impacts of contractions in Medicaid coverage. Prior to the passage of the Affordable Care Act, cancer survivors living in expansion states had better access to care than survivors living in non-expansion states. Failure to expand Medicaid could potentially leave many cancer survivors without access to routine care. The study informs policy makers that, relative to no expansion, moderate or generous expansion is associated with improvement in access to and utilization of healthcare services.


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