Naveen Manisundaram, MD

A study investigating the effect of Medicaid expansion on racial disparities in mortality among patients with gastrointestinal malignancies has found that the initiative was associated with a greater reduction in 2-year mortality rates among Black patients living in states with Medicaid expansion compared with those living in states without it. Existing racial disparities in mortality remained the same or worsened for patients living in states without Medicaid expansion but in almost all cases were mitigated for those living in states with it. The study was presented by Naveen Manisundaram, MD, a physician in the Department of Neuroscience at Baylor College of Medicine, Houston, and colleagues during the 2023 ASCO Annual Meeting.¹

Study Methodology

Studies have shown that racial minorities experience disparities in access to cancer treatment and survival.² In an effort to improve access to care for disadvantaged populations, the Affordable Care Act provided funding to states to expand Medicaid eligibility criteria and offer coverage to low-income individuals who lacked health insurance.

In this study, the researchers used the National Cancer Database (2009–2019) to conduct a cross-sectional cohort study of patients with pancreatic ductal adenocarcinoma, colorectal cancer, and gastric adenocarcinoma of any stage. Difference-in-difference (DID) analysis was performed to compare adjusted 2-year mortality separately among Black and White patients residing in Medicaid expansion states and nonexpansion states before 2009–2013 and after 2014–2019 expansion. Differences in receipt of surgery and chemotherapy were also evaluated. A negative DID analysis suggested a greater reduction in mortality for those living in Medicaid expansion states compared with those living in non–Medicaid expansion states.

Key Results

The researchers included 86,052 patients in their analysis—19,188 patients with pancreatic ductal adenocarcinoma, 60,404 patients with colorectal cancer, and 6,460 patients with gastric adenocarcinoma. They found that the 2-year mortality decreased among Black patients with pancreatic ductal adenocarcinoma residing in Medicaid expansion states compared with nonexpansion states following expansion (DID = –9.4%, P < .001). Mortality also decreased among Black and White patients with colorectal cancer in Medicaid expansion states compared with nonexpansion states following expansion (DID = –4.2%, P < .001 and –2.9%, P = .047).

Among patients with gastric adenocarcinoma, Black patients in Medicaid expansion states experienced a marked reduction in mortality compared with those in nonexpansion states (DID = –7.7%, P = .07). Both Black and White patients with stage III or IV pancreatic ductal adenocarcinoma had an increase in the receipt of chemotherapy in Medicaid expansion states following expansion (DID = 3.7%, P = .28 and DID = 2.7%, P = .2). The study also found that the rates of surgery, but not chemotherapy receipt, increased among Black patients with stage IV colorectal cancer in Medicaid expansion states following expansion (DID = 5.7%, P = .03 and 1.0%, P = .66, respectively). A greater increase in receipt of chemotherapy was observed among Black patients with stage IV gastric adenocarcinoma in Medicaid expansion states than in nonexpansion states (DID = 11%, P = .06).

“Medicaid expansion was associated with a greater reduction in 2-year mortality rates for Black patients residing in [Medicaid expansion states] than for those in [nonexpansion states]. Existing racial disparities in mortality remained the same or worsened in [nonexpansion states] but in almost all cases were mitigated in [expansion states] following Medicaid expansion,” concluded the study authors.

Reducing Health Disparities in Cancer Care

At an ASCO press briefing where this study’s findings were presented, Dr. Manisundaram commented that the study showed expanding Medicaid could reduce survival disparities between Black and White patients with cancer.

“Expanding Medicaid is one attainable and concrete solution that has been found to be associated with improved survival outcomes,” said Dr. Manisundaram. “Additionally, Medicaid expansion can serve as a solution to reduce survival disparities between Black and White patients.

Press briefing moderator Julie R. Gralow, MD, FACP, FASCO, Chief Medical Officer and Executive Vice President of ASCO, noted that a strength of the study is it showed the results in access to care in states before and after Medicaid expansion.

“This is a terrific analysis,” said Dr. Gralow. “We’ve seen many analyses looking at Medicaid expansion and its impact. I think the strength of this one is that we have pre- and postexpansion and have the states that expanded Medicaid and those that didn’t. [The authors were] able to show in particular that Black patients had benefit from Medicaid expansion, and access to care was improved in the form of chemotherapy and surgery. Forty states and the District of Columbia have now expanded Medicaid. A couple of those states have just expanded Medicaid in 2023—it hasn’t actually gone into effect yet. We’ve got 10 states now without expanded access to Medicaid. Hopefully, with solid data like this we’ll be able to provide evidence that Medicaid expansion and the resultant improvement in care can help overcome the inequities in access [to cancer care].” 

DISCLOSURE: Funding for this study was provided by the U.S. National Institutes of Health. Dr. Manisundaram and Dr. Gralow reported no conflicts of interest.

REFERENCES

1. Manisundaram N, Snyder RA, Hu CY, et al: Racial disparities in cancer mortality in patients with gastrointestinal malignancies following Medicaid expansion. 2023 ASCO Annual Meeting. Abstract 6546. Presented June 3, 2023.

2. Tong M, Hill L, Artiga S: Racial disparities in cancer outcomes, screening, and treatment. KFF, February 3, 2022. Available at www.kff.org/racial-equity-and-health-policy/issue-brief/racial-disparities-in-cancer-outcomes-screening-and-treatment/. Accessed June 1, 2023.