Medicaid Expansion Helped Reduce Disparities Among Different Groups With Cancer

The expansion of Medicaid may mitigate health disparities in cancer diagnosis, according to a recent study that found state variation in reductions in the percentage of uninsured patients aged 18 to 64 years diagnosed with cancer. The researchers said that the results have implications for future disparities in state mortality rates, because health insurance coverage is linked to the ability to have better treatment and survival after diagnosis.

The study examined how insurance status and stage at diagnosis changed by state, and by factors including race/ethnicity, Census tract—level poverty, and rurality, among patients with newly diagnosed cancer after implementation of the Affordable Care Act (ACA). Other studies have found that Medicaid expansion increased the diagnosis of early-stage cancers, but those studies have only assessed the aggregate effects of state expansions.

A main goal of the ACA is to significantly reduce the number of those without health insurance by providing a range of affordable coverage options through Medicaid and the health insurance marketplaces. The ACA expands Medicaid coverage for most low-income adults to 138% of the federal poverty level.

This population-based registry study of 2.5 million patients with cancer used data from the North American Association of Central Cancer Registries. Patients were diagnosed from 2010 to 2014 in 40 states, representing 80% of the cancer population in the United States. The median age was 52.7 years; just over half were female, and nearly 71% were white.

While the percentage of uninsured patients fell in almost all states, the largest decreases happened in Medicaid expansion states with high rates of uninsured individuals.

Disparities in the percentage of uninsured patients by race/ethnicity, Census tract—level poverty, and rurality were diminished or eliminated in expansion states but remained high in nonexpansion states, highlighting the role of Medicaid expansion in reducing disparities.

In expansion states, the decreases in the percentage of uninsured patients were higher among minorities and patients in high-poverty or rural areas. In addition, most cancer types were diagnosed at earlier stages in Medicaid expansion states.

The percentage of uninsured patients decreased from 8.3% before implementation of the ACA to 2.1% (a 6.2-percentage-point difference) after implementation of the ACA in the expansion state of Kentucky. In the nonexpansion state of Tennessee, the percentage of uninsured before the ACA stood at 9.1%, falling to 7.5% (1.5-percentage-point difference) after implementation.

Groups that benefitted from Medicaid expansion versus those living in nonexpansion states, seeing a larger drop in the rate of those who were uninsured, included:

• Males (2.8 percentage points vs 2.4 percentage points, respectively), especially among Hispanic patients (4.5 vs 3.6 percentage points),
• Minority groups (>4 percentage points for non-Hispanic blacks and Hispanics vs 2.3 percentage points for whites)
• Those living in higher Census tract—level poverty areas (4.6 percentage points for the lowest-income individuals vs 1.3 percentage points for the highest-income individuals)
• Rural residents (4.3 percentage points for rural vs 2.5 percentage points for urban)

Before implementation of the ACA, the percentage of uninsured patients in nonexpansion states was 4.9 percentage points higher than that in expansion states among those living in the lowest-income Census tracts. The difference widened to 8.5 percentage points in 2014; similarly, the difference among rural residents widened from 2.1 percentage points to 5.6 percentage points after implementation of the ACA.

In addition, the difference in the percentage of uninsured patients between those residing in the lowest-income neighborhoods in expansion states and in affluent neighborhoods in nonexpansion states was nearly eliminated after implementation of the ACA, from 4.7 percentage points to 0.9 percentage points.

Reference

Han X, Yabroff R, Ward E, Brawley OW, Jemal A. Comparison of insurance status and diagnosis stage among patients with newly diagnosed cancer before vs after implementation of the Patient Protection and Affordable Care Act [published online August 23, 2018]. JAMA Oncol. doi: 10.1001/jamaoncol.2018.3467.