According to a recent report by The Commmonwealth Fund, “large racial and ethnic health inequities, driven by factors both inside and outside the health-care delivery system [in the United States], are common.” The result, according to the report, is that actions that could mitigate health inequities—for example, through expanding eligibility for Medicaid as provided for under federal law—are not being implemented.

The findings from a study by Barnes et al show how state public welfare spending reduces racial and ethnic disparities in cancer care and improves overall survival for newly diagnosed patients with cancer. According to the study’s results, increased public welfare spending was associated with increased 5-year overall survival among non-Hispanic Black patients (2.02% per 10% increase in spending). In addition, increased public spending was linked with narrowing Black vs White 5-year overall survival disparity for many cancer sites. The study will be presented during the 2022 ASCO Annual Meeting (Abstract 6509).

Study Methodology

The researchers queried adults aged 18 and older who were diagnosed with cancer between 2007 and 2016 from the Surveillance, Epidemiology, and End Results Program, and identified 2,925,550 individuals for the study. They then obtained annual state spending data from the U.S. Census Bureau and evaluated the association of 5-year overall survival and public welfare spending using cluster-robust regression.

The investigators analyzed the data by race/ethnicity and by cancer site. To determine whether public welfare spending was associated with changes in racial and ethnic disparities in survival, they additionally assessed for interaction effects between public welfare spending and race and ethnicity. Analyses were adjusted for covariates including age; sex; metropolitan residence; state; county-level income and education; insurance status; cancer site; stage at diagnosis; and year of diagnosis.

Sensitivity analyses were conducted also accounting for state Medicaid expansion effects and state spending on health care and hospitals.

Results

Increasing social services spending was associated with increased 5-year overall survival among non-Hispanic Black patients, resulting in a decrease in racial disparities in survival between non-Hispanic Black and White patients for many different types of cancers. Five-year overall survival was 10.8% lower in non-Hispanic Black compared to non-Hispanic White patients for all cancers combined.

There was a 4.55% narrowing of the 5-year overall survival disparity in non-Hispanic Black patients compared to non-Hispanic White patients per 10% increase in spending.

Specifically, increased public welfare spending was associated with a narrowed Black vs White 5-year overall survival disparity for patients with breast (a 6.15% survival increase for Black patients led to a 39% closing of the disparity); cervical (a 11.9% survival increase led to a 46% closing of the disparity); colorectal (a 4.42% survival increase led to a 48% closing of the disparity); head and neck (a 9.41% survival increase led to a 38% closing of the disparity); liver (a 7.02% survival increase led to a 49% closing of the disparity); ovarian (an 8.95% survival increase led to a 41% closing of the disparity); bladder (an 8.18% survival increase led to a 44% closing of the disparity); and uterine (a 14.1% survival increase led to a 40% closing of the disparity).

The study found that results were similar after accounting for state health care and hospital spending and state Medicaid expansion effects.

“State investment in public welfare was associated with improved 5-year overall survival for non-Hispanic Black individuals with cancer, decreasing racial disparities in cancer outcomes overall and for many cancer sites,” concluded the study authors.

The researchers hope to more closely examine the various components of public welfare expenditures to better determine which components play the most important roles. Also, they are considering additional studies to compare changes in outcomes with changes in welfare policies over time, thereby helping confirm the associations observed in this study.

Perspective

“This study underscores the critical role that state social welfare spending, including Medicaid expansion, plays in reducing cancer outcome disparities. State-funded programs can reduce barriers to accessing cancer care and impact survival,” said ASCO Chief Medical Officer and Executive Vice President Julie R. Gralow, MD, FACP, FASCO, in a statement.

Disclosure: For full disclosures of the study authors, visit coi.asco.org.