States that adopted Medicaid expansion after passage of the Affordable Care Act (ACA) in 2010 saw a decline in cancer mortality rates by 29% compared with 25% in states that did not expand access to Medicaid, according to a study by Anna Lee, MD, MPH, of Memorial Sloan Kettering Cancer Center, New York, presented during a press briefing prior to the ASCO20 Virtual Scientific Program.1 Of the minority groups assessed, Hispanic patients had the highest differential cancer mortality benefit in states with Medicaid expansion. Cancer mortality overall was worse for black patients in states without Medicaid expansion than in states with expanded coverage. In expanded states, the estimated drop in cancer deaths among all patients in 2017 was 785.
A central goal of the ACA, enacted into law in 2010, is to significantly reduce the number of uninsured Americans by providing affordable insurance coverage options through Medicaid and the Health Insurance Marketplace. The law expands Medicaid coverage for most low-income adults to 138% of the federal poverty level. As of April 2020, 37 states, including the District of Columbia, have expanded Medicaid coverage.
The researchers analyzed age-adjusted mortality rates per 100,000 from the National Center for Health Statistics database from 1999 to 2017 to establish trends. They included only deaths due to cancer in patients younger than age 65. Absolute change in cancer mortality was calculated from 2011 to 2013 and from 2015 to 2017 (with 2014 as a washout year). Changes within subpopulations (gender, race, and ethnicity) were also assessed. Mortality changes between expanded and nonexpanded groups were analyzed using a statistical technique called difference in differences.
The researchers found that from 1999 to 2017, overall age-adjusted cancer mortality in the United States fell from 66.9 to 48.8 per 100,000. States that expanded Medicaid coverage had higher populations (157 vs 118 million) with fewer black/African Americans (19.2 vs 21.8 million) and more Hispanics (33.0 vs 21.7 million) than nonexpanded states (all examples from 2017).
The overall age-adjusted cancer mortality was consistently worse in the nonexpanded states. Cancer mortality fell from 64.7 to 46.0 per 100,000 in expanded states and from 69.0 to 51.9 per 100,000 in nonexpanded states from 1999 to 2017 (both trends P < .001, comparison P < .001). When the researchers compared the mortality changes in the peri-ACA years (2011–2013 vs 2015–2017) between the two cohorts, they found the difference in differences between expanded and nonexpanded states was –1.1 and –0.6 per 100,000, respectively (P = .006 expanded, P = .14 nonexpanded).
The estimated overall cancer mortality benefit gained in expanded states after Medicaid expansion is –0.5 per 100,000 (P = nonsignificant). In expanded states, this translates to an estimated 785 fewer cancer deaths in 2017.
Age-adjusted cancer mortality per 100,000 was worse in nonexpanded states for black patients (58.5 expanded vs 63.4 nonexpanded in 2017); however, there was no differential mortality benefit after ACA expansion when comparing between the peri-ACA years. Of the subpopulations assessed, the researchers found that Hispanics in expanded states had the highest differential cancer mortality benefit at –2.1 per 100,000 (P = .07).
“This is the first study to show a directly measured cancer survival benefit from the ACA on a national scale using a comprehensive database. Hispanic populations appear to have the highest differential cancer mortality benefit after Medicaid expansion. Further study is needed to elucidate why other populations like black patients did not appear to reap the same mortality decrease,” concluded the study authors.
“This study provides needed data to understand the effects of Medicaid expansion on cancer care. Better access to quality cancer care, in this case through state expansion of Medicaid, led to fewer cancer deaths,” said Richard L. Schilsky, MD, FACP, FSCT, FASCO, Chief Medical Officer and Executive Vice President of ASCO, in a statement.
DISCLOSURE: For full disclosures of the study authors, visit asco.org.
1. Lee A, Shah K, Chino J, et al: Changes in cancer mortality rates after adoption of the Affordable Care Act. ASCO20 Virtual Scientific Program. Abstract 2003. Presented in premeeting press briefing May 12, 2020.