From the Journals

Reduced cancer mortality with Medicaid expansion



Medicaid expansion under the Affordable Care Act was associated with a significant reduction in breast, colon, and lung cancer mortality, likely because of earlier stage of cancer diagnosis, according to a review published in JAMA Network Open.

Researchers reviewed data on 523,802 patients in the National Cancer Database who were diagnosed with cancer from 2012 through 2015. Slightly more than half of patients (55.2%) lived in Medicaid expansion states.

After expansion, mortality significantly decreased in expansion states (hazard ratio, 0.98; P  = .008) but not in nonexpansion states (HR, 1.01; P  = .43). The difference was significant in a difference-in-difference analysis (HR, 1.03; P = .01).

Across 69,000 patients with newly diagnosed cancer in Medicaid expansion states, the 2% decrease in the hazard of death would translate to 1,384 lives saved annually.

The benefit was primarily observed in patients with nonmetastatic cancer. For patients with stage I-III cancer, the risk of death was increased in nonexpansion states (HR, 1.05; P < .001) and unchanged in expansion states (HR, 0.99; P = .64). Mortality significantly improved in expansion states vs. nonexpansion states (HR, 1.05; P = .003).

For patients with stage IV cancer, both expansion and nonexpansion states had improvements in mortality, but the differences were not significant.

“Earlier stage at diagnosis appears to explain the mortality improvement,” wrote study author Miranda Lam, MD, of Harvard Medical School, Boston, and colleagues.

Clinical benefits, ‘no economic downside’

Under the Affordable Care Act, passed in 2010, states have the option of expanding Medicaid eligibility to adults with incomes at or below 138% of the federal poverty level. As of March 2020, 36 states and the District of Columbia had expanded Medicaid, with more than 20 million residents obtaining coverage.

Previous studies have associated Medicaid expansion with fewer patients being uninsured, increased cancer screening, and earlier stage of diagnosis, as well as reduced racial disparities in access to high-volume hospitals for cancer surgery and increased rates of cancer surgery among low-income patients.

“This study adds to an increasingly large body of research finding that Medicaid expansion has improved our ability to fight cancer,” said Coleman Drake, PhD, of the University of Pittsburgh, who was not involved in this study.

“Obtaining health insurance through Medicaid allows patients to receive recommended preventive cancer screenings, which explains the increase in early-stage diagnosis rates. Detecting cancer early is critical for successful cancer treatment,” Dr. Drake noted.

“It is hard to overstate the positive effects of Medicaid expansion on health outcomes. At the same time, concerns that Medicaid expansion would be costly to state governments’ budgets have not been realized. In short, Medicaid expansion yields many benefits and has no economic downside for state policymakers. Clinical and economic evidence make an overwhelming case for states to expand Medicaid,” Dr. Drake said.

Significant difference for lung cancer

Most patients in this study were women (73.6%), and the patients’ mean age was 54.8 years (range, 40-64 years). Patients had newly diagnosed breast cancer (52.2%), colorectal cancer (21.3%), and lung cancer (26.5%).

The benefits of Medicaid expansion persisted after adjustment for education, income, insurance, and race.

The lower mortality in expansion states compared with nonexpansion states was similar across all three cancer types. However, in stratified analyses, the difference was significant only for lung cancer (P = .03).

“Lung cancer has a higher mortality rate than breast and colorectal cancer, and with longer follow-up, it is possible that the lower mortality rates seen for breast and colorectal cancer may also become significant,” the authors wrote.

This research was funded by Harvard Catalyst, the Harvard Clinical and Translational Science Center, and the National Center for Advancing Translational Sciences at the National Institutes of Health. The investigators and Dr. Drake had no relevant disclosures.

SOURCE: Lam MB et al. JAMA Netw Open. 2020 Nov 2;3(11):e2024366.

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