Medicaid expansion associated with decreased mortality in breast, lung, colorectal cancers
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Medicaid expansion after passage of the Affordable Care Act appeared associated with decreased mortality among patients with newly diagnosed breast, colorectal or lung cancer, according to study results published in JAMA Network Open.
The decrease in expansion vs. nonexpansion states may be a result of more cancers being diagnosed at an early stage, researchers noted.
“Based on our current analysis showing improved mortality in Medicaid expansion states compared with nonexpansion states, our hypothesis is that additional lives could be saved if every state expanded Medicaid,” Miranda Lam, MD, MBA, assistant professor of radiation oncology at Harvard Medical School and radiation oncologist at Dana-Farber Cancer Institute, told Healio.
The ACA allowed states to expand Medicaid to nonelderly adults whose incomes are at or below 138% of the federal poverty level in participating states.
As of March, 36 states and Washington, D.C., adopted Medicaid expansion, leading to more than 20 million Americans gaining coverage. Two additional states, Missouri and Oklahoma, have adopted but not yet implemented Medicaid expansion.
Studies of patients with cancer have shown associations between Medicaid expansion and fewer patients being uninsured, as well as increased screening and earlier-stage diagnoses. They also showed mixed results regarding racial and socioeconomic disparities.
Lam and colleagues used data from the National Cancer Database to conduct a difference-in-difference, cross-sectional, population-based study of 523,802 patients (mean age, 54.8 years; 73.6% women) with newly diagnosed invasive breast (n = 273,272), lung (n = 138,810) or colorectal (n = 111,720) cancer between 2012 and 2015 to determine whether expansion of Medicaid coverage had an impact on mortality rates.
Among all patients, 289,330 (55.2%) lived in Medicaid expansion states.
Results showed that, after Medicaid expansion, mortality decreased in expansion states (HR = 0.98; 95% CI, 0.97-0.99). However, it did not decrease in nonexpansion states (HR = 1.01; 95% CI, 0.99-1.02).
The difference-in-difference analysis — for which an HR greater than 1 indicates a greater improvement in expansion vs. nonexpansion states, or less worsening in expansion vs. nonexpansion states — showed the improvement in mortality in expansion states appeared significantly different than the unchanged mortality in nonexpansion states (HR = 1.03; 95% CI, 1.01-1.05).
In an analysis looking at cancer stage, researchers observed a 4.8% increased hazard for death among patients with nonmetastatic cancer in nonexpansion states (HR = 1.05; 95% CI, 1.02-1.05), with unchanged mortality in expansion states (HR = 0.99; 95% CI, 0.97-1.02) and significantly improved mortality in expansion vs. nonexpansion states in the difference-in-difference analysis (HR = 1.05; 95% CI, 1.02-1.09).
After adjusted for education, income, insurance and race, the mortality reduction for expansion states persisted (HR = 0.98; 95% CI, 0.96-0.99). However, the association lost significance after adjusting for cancer stage (HR = 1; 95% CI, 0.98-1.02), as did the difference-in-difference analysis (HR = 1; 95% CI, 0.98-1.02).
These data suggest the survival differences were mediated by cancer stage, and that the decline in mortality associated with Medicaid expansion occurred due to earlier cancer diagnosis, according to the researchers.
“It is unclear whether these results would be similar for other types of cancer, and that is a great next question to look into,” Lam told Healio. “It is possible that providing coverage allows patients to access the health care system for issues or concerns, and that could lead to earlier diagnoses, even without screening. However, without analyzing other cancer types, we will not know for certain.”
For more information:
Miranda B. Lam, MD, MBA, can be reached at miranda_lam@dfci.harvard.edu.
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