Medicaid Expansion Associated With More Early-Stage Cancer Diagnoses

Medicaid expansion under the Affordable Care Act (ACA) has been linked to various improved outcomes in cancer, from fewer newly diagnosed cases of late-stage cancer to decreased cancer mortality. In a new analysis published in the American Journal of Preventive Medicine, data showed that expansion had positive effects on rates of early cancer diagnosis, and the results were immediate.¹

The study comes during a week in which the ACA was in the spotlight as the US Supreme Court heard arguments for and against the law that Republican-led states and the Trump administration are challenging once again. Statements from some justices Tuesday suggested that the court was poised to uphold the main components in the act, despite plaintiffs' arguments that the entire ACA must fall if the individual mandate provision is deemed unconstitutional.

“It does seem fairly clear that the proper remedy would be to sever the mandate provision and leave the rest of the act in place—the provisions regarding pre-existing conditions and the rest,” Justice Brett Kavanaugh said.² He and Chief Justice John Roberts, a fellow conservative who nonetheless upheld the ACA in its original trip to the court, seemed to have similar thoughts on the matter. This could mean most of the act stays intact if they align with the court’s 3 liberal justices, but a decision is not expected until June 2021.

Study results. “Our study adds to the literature demonstrating the positive health effects of Medicaid expansion,” senior author Coleman Drake, PhD, assistant professor in Pitt Public Health’s Department of Health Policy and Management, said in a news release.³ “This is another case where, depending on the Supreme Court’s ruling, the beneficial effects of preventive care provided by Medicaid expansion could disappear.”

The population-based, quasi-experimental analysis included non-elderly adults in 732 counties. Researchers used data from the 2010-2016 Surveillance, Epidemiology, and End Results Program (SEER) cancer registry data to track cancer diagnoses for 3 years post-expansion. The data were analyzed from May to October 2019, and the rates of cancer diagnoses in Medicaid expansion states were compared with states that did not expand using estimated multivariate event study regressions.

In Medicaid expansion states, there was an increase in early-stage diagnoses within a year of the expansion. There were 21.3 more early-stage diagnoses per 100,000 population, or 9.14% of population within the first year.

Years 2 and 3 did not see statistically significant increases in early-stage diagnoses, but there was a decrease in late stage diagnoses by 8.7 per 100,000 population, or 5.7% of population 3 years after Medicaid expansion compared with baseline. Total diagnoses overall did not change.

“We used cancer diagnosis rates as a marker of access to care,” lead author Lauren Lin, BS, a medical student at Pitt School of Medicine, said in a release. “An increase in early-stage cancer diagnoses means that people who didn’t have health care before the Medicaid expansion got a chance to see a primary care physician and get screened.”

Study authors concluded that the significant increase in diagnoses in the first year and the plateau that followed suggest that there was a pent-up demand for screening and diagnostic services that was met to some degree after expansion. The slight reduction in late-stage diagnoses seen in year 3 might indicate the potential role of public health insurance on improving outcomes in cancer among non-elderly adults, they added.

“It is important to remember that while the ACA was passed 10 years ago, the key provisions weren’t implemented until 2014,” co-author Lindsay Sabik, PhD, associate professor of health policy and management at Pitt Public Health and member of the UPMC Hillman Cancer Center, said. “Because we often don’t see the effects immediately, it’s important for us to keep studying the long-term consequences of health care reform.”

References

1. Lin L, Soni A, Sabik L, Drake C. Early- and Late-Stage Cancer Diagnosis Under 3 Years of Medicaid Expansion. Am J Prev Med. Published online November 11, 2020. doi:10.1016/j.amepre.2020.06.020

2. Liptak A. Key Justices Signal Support for Affordable Care Act. New York Times. November 10, 2020. Accessed November 12, 2020. https://www.nytimes.com/2020/11/10/us/supreme-court-obamacare-aca.html​

3. Increase in Early-Stage Cancer Tied to ACA’s Expansion. News Release. University of Pittsburgh Schools of the Health Sciences; November 12, 2020. Accessed November 12, 2020. https://www.upmc.com/media/news/111220-ajpm-aca​