NSCLC-Related Mortality Improves in Medicaid Expansion States

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

AFFORDABLE CARE ACT

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The Affordable Care Act (ACA) was first signed into law on March 30, 2010,² and the dates for this analysis covered patients with NSCLC (N = 14,984) who underwent surgical resection between 2008 and 2019 in any of the 27 states that had expanded Medicaid coverage by 2014. Before ACA implementation encompassed 2008 to 2013 and post ACA implementation, 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 at these ages 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 write. “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.”

Proposed reasons for better mortality among this patient population include better health condition management and not delaying seeking care, they add.

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

Before and after the ACA, patients in nonexpansion states were older vs patients in expansion states: 42.2 vs 39.7 years and 32.2 vs 27.9 years. Diagnose rates among female and male patients were equivalent in the pre- and post-ACA periods, hovering around 46% and 44% for female patients, respectively, and 53% and 55% for male patients.

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).

A third 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 own 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 policymakers 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://www.hhs.gov/answers/health-insurance-reform/what-is-the-affordable-care-act/index.html#:~:text=The%20Patient%20Protection%20and%20Affordable,Act%20on%20March%2030%2C%202010