“This study provides needed data to understand the effects of Medicaid expansion on cancer care. Better access to quality cancer care, in this case through state expansion of Medicaid, leads to fewer cancer deaths,” said ASCO Chief Medical Officer and Executive Vice President Richard L. Schilsky, MD, FACP, FSCT, FASCO.
ALEXANDRIA, Va. — States that adopted Medicaid expansion following passage of the Affordable Care Act (ACA) of 2010 saw greater decreases in cancer mortality rates than states that did not, according to the first nationwide study of its kind.
Study at a Glance
Cancer mortality rates between states that did and did not expand Medicaid
Patients under age 65 from the National Center for Health Statistics database from 1999-2017
Baseline age-adjusted cancer mortality rates were lower in states that expanded the ACA and declined more over time. Cancer mortality declined by 29% in states that expanded Medicaid and by 25% in those that did not. Additional cancer mortality benefit was specifically noted after 2014 expansion.
Medicaid expansion is associated with a reduction in cancer deaths
The study will be presented during the virtual scientific program of the 2020 American Society of Clinical Oncology (ASCO) Annual Meeting.
The researchers identified overall trends for age-adjusted cancer mortality in the United States from 1999-2017. States that expanded Medicaid saw a 29% decline, falling from 65.1 to 46.3 per 100,000 individuals in that period; whereas rates dropped by 25%, from 69.5 to 52.3 per 100,000 in states that did not. When specifically looking at the changes after 2014 expansion, the additional mortality benefit for states that adopted Medicaid expansion amounted to an estimated 785 fewer cancer deaths in 2017 alone.
"This is the first study to show the benefit of Medicaid expansion on cancer death rates on a national scale,” said Anna Lee, MD, MPH, who is the lead author and radiation oncology fellow at Memorial Sloan Kettering Cancer Center (MSK) in New York. “We now have evidence that Medicaid expansion has saved the lives of many people with cancer across the United States,” she added.
Granting states permission to expand Medicaid coverage to more people was one of the key components of the ACA. Medicaid is administered by the states and provides health care coverage for eligible people with disabilities or very low incomes. Many states formally adopted Medicaid expansion in January 2014; those states that participated saw large increases in Medicaid enrollment, including people with incomes near the poverty level who were newly eligible as well as those who had been eligible but had not enrolled previously.
About the Study
The data comes from the National Center for Health Statistics and includes all U.S. residents. The researchers established baseline trends from 1999 to 2017 and then compared age-adjusted rates between 2011-2013 (prior to full state expansion) and 2015-2017 (the period following expansion) for states that adopted Medicaid expansion and those that did not. Deaths due to cancer in patients age 65 or older were not included in the analysis, as those patients are eligible for Medicare.
The researchers gathered age-adjusted cancer mortality rates from each state and grouped the states into those that expanded Medicaid and those that did not. During the time period of their analysis, 27 states plus the District of Columbia had adopted Medicaid expansion, while 23 states had not.
The researchers also looked at changes in sub-populations, including patients who were black or Hispanic. Although there were large mortality gains during the study period for patients who were black, no additional mortality reduction was seen in this population in states with Medicaid expansion. However, age-adjusted cancer mortality overall was consistently worse for black patients in states without expansion than in states with expansion (58.5 vs 63.4 per 100,000 for the expansion and non-expansion states respectively).
In contrast, the greatest differential change in cancer mortality rates between expansion and non-expansion states was seen for Hispanic patients, although there was significant variation in year-to-year mortality seen in this population.
“There is a greater Hispanic population in states that have adopted Medicaid expansion, and they have almost three times the un-insurance rate as white adults,” said senior author Fumiko Chino, MD, a radiation oncologist at MSK. “Our research shows that Hispanic patients with cancer may have benefited the most because they had the most to gain.”
For the study analysis, the researchers used a statistical technique called difference-in-differences. They calculated the difference in mortality rates between the two periods for expansion and non-expansion states, and then calculated the difference between these values. The intent is to mitigate the effects of baseline population differences and other differences in access at the state level.
Comparing the mortality changes before and after ACA expansion, the difference in differences was -1.1 and -0.6 per 100,000 for expansion and non-expansion states respectively (p=0.006 expanded, p=0.13 non-expanded).
As new yearly data becomes available through the National Center for Health Statistics, the researchers plan to add to their analysis.
For your readers:
The Affordable Care Act and Cancer
ASCO Annual Meeting 2019: Treatment Advances for Metastatic Prostate Cancer and Pancreatic Cancer, Multiple Myeloma Survival Factors, and Effects of the Affordable Care Act on Cancer Care
View the disclosures for the 2020 Cancer Communications Committee: https://www.asco.org/sites/new-www.asco.org/files/content-files/about-asco/pdf/2020-am-ccc-disclosures.pdf
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