Fewer Cancer Deaths After ACA Medicaid Expansion

Roxanne Nelson, RN, BSN

May 14, 2020

States that adopted Medicaid expansion following the implementation of the Affordable Care Act (ACA) had a greater decrease in cancer mortality rates compared with states that did not, a new analysis shows.

Overall, cancer mortality declined by 29% in states that expanded Medicaid and by 25% in those that did not.

This translates to an estimated 785 fewer cancer deaths in 2017 in the states  that expanded Medicaid, said lead author Anna Lee, MD, MPH, a radiation oncology fellow at Memorial Sloan Kettering Cancer Center in New York City. "We estimate that an additional 589 cancer deaths could have been prevented if non-expanded states had expanded Medicaid."

This is the first study to show a directly measured cancer survival benefit from Medicaid expansion under the ACA, she commented.  

The greatest mortality benefit was observed in Hispanic patients. "There was significant baseline variability in survival in Hispanic patients, which may reflect known poor access to healthcare in this population," she said.

Lee presented her findings in a virtual session for journalists held in advance of the virtual scientific program of the 2020 American Society of Clinical Oncology (ASCO) Annual Meeting. 

"This study is important because it's looking at national data," commented Ernest Hawk, MD, MPH, vice president and division head for Cancer Prevention and Population Sciences at the University of Texas MD Anderson Cancer Center in Houston.

The Affordable Care Act had many different aspects that would contribute to reductions in cancer mortality, he noted. The reduction in cancer mortality over the interval period "was probably the result of improved screening as well as improvements in treatments that occurred during this period, and improved access to treatment," he told Medscape Medical News.

Hawk emphasized that this study "synthesizes much of the effect of the Affordable Care Act in extending screening and getting treatment to the populations who need it."

The second message is that, even though cancer mortality improved across the board, the expanded states showed a greater benefit. "This is important, because it shows that at least some of this improvement can be attributed to the expansion of insurance," he said.

Since the time frame of this study, about eight or nine additional states have opted into Medicaid expansion, so mortality rates have probably improved even further, he noted.

Lower Mortality in Expanded States

The Affordable Care Act (ACA) was designed to improve health status in the US primarily through improving access to health insurance. Once implemented, 20 million people who were uninsured were able to obtain insurance coverage.

One of the goals of the ACA was to provide equity in healthcare access and outcomes by allowing the expansion of Medicaid coverage, along with providing subsidies for purchase of private insurance. However, the decision to expand Medicaid was left up to individual states.

By 2015, Medicaid had expanded in 27 states plus Washington DC, while 23 states had opted out.

There are about 1.8 million new cancer diagnoses in the US every year. "Cancer is a disease that is considered to be 'healthcare amenable' in which access to healthcare is expected to improved outcomes," Lee explained.

Results of a previous study, which were presented last year at ASCO's annual meeting and reported by Medscape Medical News, found that Medicaid expansion almost completely eliminated racial disparities between black and white patients, in regards to receiving timely cancer treatment.

The goal of the current study was to see if there was an additional mortality benefit between states that expanded Medicaid and those that did not.

The team looked at data from the National Center for Health Statistics, specifically at age-adjusted mortality rates per 100,000, from 1999 to 2017, in order to establish trends. Only cancer deaths in patients under the age of 65 years were included.

The absolute change in cancer mortality was calculated for the period 2011–2013 (prior to full state expansion) and then 2015–2017 (the period following expansion), with 2014 as a washout year, for states that adopted Medicaid expansion and those that did not.

Overall, age-adjusted cancer mortality declined during the entire study time period (1999–2017), from 66.9 to 48.8 per 100,000 people. But mortality was consistently worse in states that had not opted for Medicaid expansion.

In states with expansion, cancer mortality declined from 64.7 to 46.0 per 100,000, compared with a fall from 69.0 to 51.9 per 100,000 in the non-expanded states (both trends P < .001, comparison P < .001).

When the changes in mortality were compared between the two groups, the differences between expanded and non-expanded states was -1.1 and -0.6 per 100,000 respectively (P = .006 and P = .14).

The team also looked at changes in subpopulations, including black and Hispanic patients.

Although there was an overall improvement in mortality during the study period for black patients, an additional mortality benefit wasn't observed after Medicaid expansion. However, cancer mortality overall was consistently worse for black patients in states without expansion vs those with expansion (58.5 vs 63.4 per 100,000, in 2017).

"Blacks have the highest absolute cancer mortality," said Lee, "But mortality rates in the black population were already improving at a greater rate than among whites and Hispanics. That may be why we were unable to find a differential benefit for Medicaid expansion in this population."

Of the subpopulations that were evaluated, Hispanics living in expansion states achieved the highest differential cancer mortality benefit at -2.1 per 100,000 (P = .07). There is a greater Hispanic population in the states with expansion, and Hispanics are almost three times as likely as white patients to lack insurance or be underinsured.

"Hispanic patients seemed to reap the most benefit with the greatest mortality decrease," said Lee. "There was significant variation in year-to-year mortality, which may reflect known poor access to healthcare in this population."

Lee and her colleagues will be adding to their analysis as new yearly data become available through the National Center for Health Statistics.

"This study provides interesting evidence supporting an association between the adoption of Medicare expansion and decreased cancer mortality," Deborah Marshall, MD, MAS, a research fellow at the Tisch Cancer Institute at Mount Sinai Health System in New York City, told Medscape Medical News. "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 Medicare expansion and decreased mortality for lower-income individuals with cancer, given the inclusion of patients of all income levels," added Marshall, who was not involved with the study.

2020 American Society of Clinical Oncology (ASCO) Virtual Scientific Program: Abstract 2003.

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