Medicaid expansion states see bigger declines in cancer mortality rates
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States that expanded Medicaid under the Affordable Care Act witnessed significant declines in cancer mortality rates compared with states that did not expand Medicaid, according to study results scheduled for presentation during the ASCO20 Virtual Scientific Program.
Hispanic populations appeared to benefit the most from Medicaid expansion, whereas others — including black patients — did not achieve the same reduction in mortality.
More study is needed on why some populations fared better than others, according to researchers.
“This is the first study to show the benefit of Medicaid expansion on cancer death rates on a national scale,” Anna Lee, MD, MPH, radiation oncology fellow at Memorial Sloan Kettering Cancer Center, said during a press conference. “We mainly looked at Medicaid expansion, but the mortality benefits we saw could also be due to other aspects of the policy, such as the online exchanges.”
The ACA aimed to improve access to health insurance, partially by allowing states to expand Medicaid coverage.
Lee and colleagues sought to compare cancer mortality rates between states that did and did not adopt Medicaid expansion. They gathered age-adjusted mortality rates per 100,000 between 1999 and 2017 from the National Center for Health Statistics, which they used to establish trends. Researchers included only deaths due to cancer among patients aged younger than 65 years, as older patients are eligible for Medicare. They then calculated absolute change in cancer mortality from 2011 to 2013 — before full state expansion — and from 2015 to 2017, after expansion. Researchers also assessed changes within subpopulations.
Twenty-seven states and the District of Columbia had adopted Medicaid expansion during the period analyzed, whereas 23 had not.
States that expanded Medicaid had a higher total population (157 million vs. 118 million) — with fewer black residents (19.2 million vs. 21.8 million) but more Hispanic residents (33 million vs. 21.7 million) — than states that did not expand Medicaid.
Overall age-adjusted cancer mortality decreased in the U.S. between 1999 and 2017, from 66.9 per 100,000 to 48.8 per 100,000. During that period, overall age-adjusted cancer mortality fell 29%, from 64.7 per 100,000 to 46 per 100,000, in states that expanded Medicaid and 25%, from 69 per 100,000 to 51.9 per 100,000, in states that did not expand Medicaid (P < .001).
Researchers evaluated mortality changes between Medicaid expansion and nonexpansion states through difference in differences analysis.
When comparing mortality changes in the years before (2011-2013) and after (2015-2017) expansion, results showed a difference in differences of 1.1 per 100,000 for expansion states (P = .006) and 0.6 per 100,000 for nonexpansion states.
Researchers reported an estimated overall cancer mortality benefit gained in states that expanded Medicaid after 2014 of 0.5 per 100,000, which translated to an estimated 785 fewer cancer deaths in 2017.
Age-adjusted cancer mortality per 100,000 worsened for black patients in states that did not expand Medicaid compared with states that did (58.5 vs. 63.4 in 2017). However, there was no differential mortality benefit following ACA expansion when comparing between the peri-ACA years, according to researchers.
Hispanics in states that expanded Medicaid, meanwhile, had the highest differential cancer mortality benefit (2.1 per 100,000) of the subpopulations analyzed.
“We think there are several reasons behind the benefit for Hispanic patients,” Lee said. “For one, a higher number of Hispanics live in states that took the Medicaid expansion. Two, they had the highest number of uninsured rates, so they had the most to gain. And three, they have the greatest year-to-year variability, and that may be related to poor documentation and poor access to care overall.” – by John DeRosier
Reference:
Lee A, et al. Abstract 2003. Scheduled for presentation at: ASCO20 Virtual Scientific Program; May 29-31, 2020.
Disclosures: Lee reports no relevant financial disclosures. Please see the abstract for all other researchers’ relevant financial disclosures.
Perspective
Back to TopDeborah Marshall, MD, MAS
This study provides interesting evidence supporting an association between the adoption of Medicaid expansion and decreased cancer mortality. With multiple states continuing to opt out of Medicaid expansion, these data are important and timely. Additionally, these data likely underestimate the magnitude of the association of Medicaid expansion and decreased mortality among lower-income individuals with cancer, given the inclusion of patients of all income levels.
These data add to the growing body evidence that Medicaid expansion improves access to care and health outcomes; in particular, the study addresses an important gap in our understanding of whether Medicaid expansion is associated with cancer mortality. Further validation is needed to understand the underlying causes of this association.
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Lee A, et al. Abstract 2003. Scheduled for presentation at: ASCO20 Virtual Scientific Program; May 29-31, 2020.
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