2019 ASCO: Medicaid Expansion and Time to Treatment in African American Patients Compared to White Patients With Cancer
Previous racial disparities in timely cancer treatment between African American and white patients were reduced in states where Medicaid access was expanded under the Affordable Care Act (ACA), according to a new analysis of electronic health records from for 30,000 patients. The study, based on data from Flatiron Health, also found that after Medicaid expansion, African American patients had the greatest rate of improvement in receiving care within 30 days of diagnosis as compared with white patients. These findings were presented during the 2019 ASCO Annual Meeting Plenary Session by Adamson et al (Abstract LBA1).
“Many studies have described racial disparities that exist in cancer care, but few have shown what types of interventions improve health equity…. We now have evidence that Medicaid expansion can mitigate certain health disparities,” said study author Amy J. Davidoff, PhD, MS, senior research scientist in Health Policy and Management at the Yale School of Public Health and a member of the Yale Cancer Center. “We also know that uncertainty about having health insurance, especially for someone newly diagnosed with cancer, can make a big difference in getting appropriate care in a timely manner.”
Two of the key components of the ACA, which became law in 2010, were granting states permission to expand Medicaid coverage to more people, and providing subsidies for people to buy private insurance if they did not qualify for Medicaid. Medicaid is administered by the states and provides 100% of health-care coverage for eligible people with very low incomes.
States were granted Medicaid expansion starting in January 2014, and those states that participated saw large increases in Medicaid enrollment, including people newly eligible as well as those who had been eligible but had not enrolled previously.
Study Methods
The researchers looked at de-identified health records from Flatiron Health’s electronic health record–derived database, which holds data on 2.2 million people diagnosed with cancer who received care at 280 community-based cancer clinics or academic medical centers, representing 800 sites of care nationwide. This analysis included data from 30,386 people aged 18 to 64 years diagnosed with advanced or metastatic solid tumors from January 2011 through January 2019.
States expanded Medicaid after the 2014 implementation of the ACA, and additional states have expanded Medicaid over time. Patients were assigned to either expanded or not expanded, based on whether the state where they lived had adopted and implemented a Medicaid expansion at the time of their diagnosis. Linked data from the Kaiser Family Foundation were used to assign expansion status.
Investigators determined whether patients received treatment within 30 days of an advanced cancer diagnosis. Time to treatment was selected as the primary outcome. Researchers tested whether Medicaid expansion was associated with reduction of racial disparities, while also accounting for age, sex, cancer type, cancer stage, state of residence, time of diagnosis, unemployment rate, and type of practice setting where treatment was received.
Key Findings
Prior to Medicaid expansion, African American patients were 4.8 percentage points less likely to receive timely treatment as compared with white patients. Researchers did not find a statistically significant increase in timely treatment after Medicaid expansion for patients overall. However, researchers then focused on whether outcomes were different between whites and African Americans, because previous studies had shown African American patients experienced the greatest burden of racial disparity.
Medicaid expansion was most beneficial for African Americans when it came to timely treatment, with a 6.1 percentage point improvement as compared with a small and statistically insignificant 2.1 percentage point increase among white patients. Racial disparities seen without Medicaid expansion diminished greatly after expansions were implemented—there was no significant difference in timely receipt of treatment between African American and white patients under Medicaid expansion.
Next Steps
The investigators are developing models to predict what treatment outcomes would be if there was no Medicaid expansion as compared with expansion in all states.
Disclosure: This study was funded by Flatiron Health. For full disclosures of the study authors, visit coi.asco.org.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
