Center on Health Equity and Access: February 2024

NSCLC-Related Mortality Improves in Medicaid Expansion States

Thirty- and 90-daysurvival outcomes were better among patients treated through surgical resection for non–small cell lung cancer (NSCLC) in Medicaid-expansion states vs nonexpansion states, according to study findings published recently in JAMA Network Open.¹

The Affordable Care Act (ACA) was signed into law on March 30, 2010,2 and the dates for this analysis covered 14,984 patients with NSCLC who underwent surgical resection between 2008 and 2019 in any of the 27 states that had expanded Medicaid coverage by 2014.

Implementation before ACA encompassed 2008 to 2013, and post ACA implementation encompassed 2014 to 2019. The National Cancer Database provided the authors the information they required to evaluate 30- and 90-day postoperative mortality outcomes, and the patient population was confined to those aged 45 to 64 years because those individuals are not yet eligible for Medicare coverage but are most likely to die following an NSCLC diagnosis.

“While in-hospital mortality is mainly associated with patients’ age and comorbidities, access to care is a major factor associated with deaths occurring after hospital discharge,” the study authors wrote.¹ “Thus, access to health insurance coverage through Medicaid expansion may be especially relevant in this population for whom access to care during recovery following hospital discharge after lung cancer surgery is vital.”
Possible reasons for better mortality among this patient population include better health condition management and not delaying seeking care, they added.

The mean (SD) patient age was 56.3 (5.1) years—62.4% were aged 55 to 64 years at diagnosis—54.6% were women, and 69.2% were non-Hispanic White individuals. Fifty-seven percent had stage I disease, 25.8% had stage II disease, and 17.0% had stage III disease. Just over 85% had no or 1 comorbidity, and the participants’ treatment facility was most often a comprehensive center (37.5%) or a teaching hospital (24.2%).¹

Before and after the ACA, patients in nonexpansion states were older than patients in expansion states: 42.2 vs 39.7 years and 32.2 vs 27.9 years, respectively. Diagnosis rates among male and female patients were similar in the pre- and post-ACA periods. For male patients, rates were at 46.7% in both expansion and nonexpansion states before the ACA, dropping to 44.8% in nonexpansion states and 43.9% in expansion states post-ACA. For female patients, diagnosis rates were 53.3% in expansion and nonexpansion states pre-ACA: post-ACA, the rates were 55.2% in nonexpansion states and 56.1% in expansion states.

The 30-day postoperative mortality rate was 0.26% for patients with NSCLC living in Medicaid expansion states (P < .001), marking a decrease from 0.97% before ACA implementation in those same states.

Nonexpansion states did not see a significant drop in this marker, with their corresponding rates being 0.75% and 0.65%, respectively (P = .74).
Results at 90 days echoed the 30-day findings, in that there was a significant drop in expansion compared with nonexpansion states. Postoperative mortality in states that expanded Medicaid coverage saw a 1.31 percentage point drop (2.63% to 1.32%; P < .001) vs a 0.23 percentage point drop in nonexpansion states (2.43% to 2.20%; P = .57). This difference between the state groupings was deemed statistically significant (P = .03).

In addition, findings on in-hospital postoperative mortality showed a difference between expansion (1.41% pre-ACA vs 0.77% post ACA) and nonexpansion (1.49% vs 1.20%, respectively) states, but this was not deemed statistically significant (P = .34).

The authors note that their findings overall show how access to care has improved following ACA expansion, citing 7 studies that came to similar conclusions among patients also aged 45 to 64 years, while highlighting that their work focused on early mortality after surgery and not on cancer survival as others have.

“Future studies should evaluate receipt of postdischarge care and estimate number of deaths averted in expansion states relative to nonexpansion states,” they concluded. “As policy makers consider whether to expand Medicaid or change different ACA provisions, these findings provide important evidence of the positive health consequences associated with coverage expansion.”

References
1. Nogueira L, Boffa DJ, Jemal A, Han X, Yabroff KR. Medicaid expansion under the Affordable Care Act and early mortality following lung cancer surgery. JAMA Netw Open. 2024;7(1):e2351529. doi:10.1001/jamanetworkopen.2023.51529
2. What is the Affordable Care Act? HHS. Accessed January 15, 2024. https://bit.ly/4aUOMpn

California Aims for Equity by Redefining Cancer Care

California’s initiative to tackle disparities in cancer care has taken a decisive step forward with the implementation of the California Cancer Care Equity Act (CCCEA). Enacted on March 1, 2023, this legislation aims to provide 13.9 million California Medical Assistance Program (Medi-Cal) beneficiaries with enhanced access to optimal cancer care services.

A Viewpoint article in JAMA Oncology highlighted key aspects of the CCCEA, such as its focus on Medi-Cal beneficiaries, the requirement for managed care plans to contract with specialized cancer centers, and the definition of complex cancers. The authors suggested potential improvements to the policy, including expanding the definition of complex cancers and addressing barriers beyond access to specialists.

The importance of ongoing monitoring and data collection to ensure the CCCEA’s effectiveness in improving access to care and reducing disparities in cancer outcomes was also emphasized. Overall, the article positioned the CCCEA as a fundamental shift in cancer health policy and advocated for its safe and effective implementation to achieve cancer equity in California.

Addressing Disparities in Cancer Care
The CCCEA mandates that Medi-Cal–managed care plans (MCMCPs) make a good faith effort to contract with specialized cancer centers capable of treating complex cancer diagnoses. Complex cancers, as defined by the bill, encompass cases where there is no standard FDA-approved treatment or where known highly effective therapies have failed. Authors said this legislative move is a crucial step toward recognizing and rectifying the disparities in access to high-quality comprehensive cancer care, particularly for Medicaid-insured patients who often experience suboptimal outcomes related to cancer diagnosis.

Expanding Access and Reducing Disparities
While the CCCEA expands the network of cancer centers within MCMCPs, the definition of complex cancers may be too narrow, the authors stated. The current criteria focus on advanced-stage cancers, potentially missing the opportunity for early intervention, which is critical for achieving better outcomes. The article suggested expanding the definition of complex cancer to include early-stage diagnoses, emphasizing the importance of multidisciplinary care for improved results.
Removing Barriers to Care
The CCCEA empowers patients by allowing them to request referrals to specialty cancer hospitals for complex cancer diagnoses. However, the authors addressed the need for clarity on how plans will facilitate these referrals. Beyond accessing specialists, the CCCEA must address other barriers such as out-of-pocket costs, transportation, health literacy, and cultural considerations. The importance of data collection to monitor the efficacy of the CCCEA, ensuring that it achieves its goal of increasing access to care and improving cancer outcomes, was stressed.

Community Partnerships for Success
While data are being collected by the California Department of Health Care Access and Information and the California Cancer Registry, the article addressed the role of community partnerships in leveraging these data. These partnerships can enhance accountability, identify patient-specific barriers, and help ensure that the CCCEA is achieving its intended effects.

The CCCEA represents a pivotal shift in cancer health policy, targeting structural and systemic drivers of disparities. The authors acknowledged the inherent trade-offs in implementing such a policy as well as the opportunities it presents to expand access to optimal cancer care services.

“Furthermore, a formal policy evaluation plan should be established to ensure that the plan is achieving cancer equity for California,” they wrote. “Doing so would reaffirm California’s commitment to improving cancer care and demonstrate to the rest of the nation a model for addressing social determinants of health and inequities in cancer care.”

Reference

Diaz A, Loehrer A, Pawlik TM. Expanding access to high-quality cancer care through policy—California Cancer Care Equity Act. JAMA Oncol. Published online November 22, 2023. doi:10.1001/jamaoncol.2023.5010

SPOTLIGHT: Michael Gieske, MD, on the Need to Address Lung Cancer Screening Disparities in Rural America

Michael Gieske, MD, director of lung cancer screening at St Elizabeth Healthcare, which serves the region around Cincinnati, Ohio, and Covington, Kentucky, discusses with Evidence-Based Oncology (EBO) disparities in lung cancer incidence and mortality that the Rural Appalachian Lung Cancer Screening Initiative aims to address.

EBO: Can you provide an overview of the Rural Appalachian Lung Cancer Screening Initiative and why increased lung cancer screenings are so important to this region and the people living there?

Gieske: With the Rural Appalachian Lung Cancer Screening Initiative, we were looking at Appalachia, of course, in particular, and then we wanted to direct our focus to an area that had really the worst of all worlds. We looked at the areas that had the worst incidence for lung cancer, the worst mortality for lung cancer, and [at] the same time, the poorest access. As it turned out, all those worst variables intersected where Kentucky, Virginia, and West Virginia come together; we picked a 10-county region there. This is recognized by the President’s Cancer Panel and Moonshot initiative, and it’s a branch of the ACCA, which is the Appalachian Community Cancer Alliance. And that alliance looks at cervical cancer screening, colon cancer screening, and breast cancer screening. We, of course, directed our interest and our efforts toward lung cancer screening. And as an offshoot of that, we formed the Rural Appalachian Lung Cancer Screening Initiative.

EBO: How is the Appalachian Community Cancer Alliance helping to identify and address disparities in equitable access to cancer care in this region?

Gieske: Well, we know there’s poor access in this region, there’s lower rates of education, there’s higher rates of poverty, and it’s a working-class, White type of poverty that we’re directing our efforts toward. The area that we’re piloting has particularly disparate health care, and we’re in the process of assimilating some data presently to find out what their screening rates are. And once we have that benchmark, then we’ll be able to go into these 3 pilot regions, introduce our efforts, and then be able to mark improvement based on where we started as a benchmark.

EBO: Can you share some insights and perspectives on why states such as Ohio, Kentucky, Pennsylvania, Virginia, and West Virginia have the highest lung cancer incidence and mortality rates across the United States?

Gieske: Kentucky really is [at] the bottom of almost every list when it comes to health care related to your lungs. We have the highest incidence of lung cancer in Kentucky in the nation. It’s 55% higher than [the] national average, and a lot of that has to do with simply geographically being located in the Tobacco Belt. Kentucky, Ohio, Tennessee, North Carolina, a lot of these states, they’ve built a lot of their traditional wealth and cultural heritage around tobacco, and it’s been a hard needle to move because tobacco and culture around smoking is so ingrained and woven into the fabric of these states.
We also have a lower rate of education in these regions, there is a higher rate of poverty in these regions, and the smoking rates are significantly higher in Kentucky. West Virginia and Kentucky battle for the bottom of that list—who has the highest smoking rate? The national average is about 14% of adults [who] smoke; in Kentucky, it’s about 22%; in West Virginia, it’s about 23%. West Virginia is presently ahead by about a nose, but that’s a big factor. Eighty percent of lung cancer is due to smoking, so when you take the lack of education, the higher poverty levels, the higher smoking rates, there are areas in eastern Kentucky where 30% to 35% of adults smoke, and you really see a lot of tobacco-related disease—and in particular, lung cancer.

SPOTLIGHT: Margaret Liang, MD, MSHPM, on Mitigating Financial Toxicity for Patients With Cancer

Margaret Liang, MD, MSHPM, gynecologic oncologist, health services researcher, and director of the Gynecologic Oncology Fellowship Program, Cedars-Sinai Cancer, spoke recently with Evidence-Based Oncology (EBO) about financial toxicity in cancer care and how institutions can help alleviate the financial burden for patients.

EBO: What are some common financial challenges that patients with cancer and their families face, and how can a well-designed financial advocacy program help address financial toxicity while ensuring access to quality care?

Liang: The biggest one that comes to mind first is really navigating the complexities of insurance. [This requires] helping patients understand what their insurance benefits are—and that may just be figuring out a minimum, like what their annual out-of-pocket maximum may be—and then having individuals who can help them navigate what’s in and out of network, and make sure that their treatments are going to be authorized, and if not, go through the appeal process with them.

The second thing that comes to mind is that drug costs are really skyrocketing. Also, there’s been more oral cancer drug therapies that are being used in oncology, and these can be very expensive and also require using specialty pharmacies. So, [this requires] having someone as part of the financial advocacy team understand how to navigate co-payment cards [or secure] free drugs from pharmaceutical companies, [and] foundation grants that have sometimes a lot of different eligibility criteria that need to be tracked.

And the third thing is really thinking about, besides all the medical costs, what are all the different things that the patients are having to do in order to adhere to their care? So, transportation, thinking about employment concerns, and possibly how it’s impacting their caregivers.

EBO: How can health care institutions engage with external stakeholders, such as insurance providers, pharmaceutical companies, and patient advocacy groups, to enhance financial support and advocacy for patients with cancer?

Liang: I think the first thing is really getting to know the local or regional community, so looking into cancer support organizations or nonprofit organizations that provide assistance to patients [and] developing standing relationships with them. The second thing is, clearly, certain things may be available in certain areas or geographies, so really leveraging the reputable national organizations that have a lot of patient-facing resources, as well as resources to help health care practices.

Lastly, really keeping an open line of communication with pharmaceutical companies. They do have a lot of financial assistance programs, like co-payment assistance programs or even free drugs, that can be accessed.

I think there can be a lot of administrative burden that comes with applying for these things or keeping up-to-date, but if you keep open lines of communication with them, you can really optimize those opportunities.