Medicare expansion under the Affordable Care Act may have improved outcomes for patients with lung cancer, the leading cause of cancer death in the United States, according to data presented at the 2021 ASCO Quality Care Symposium.1
The National Cancer Database analysis of nearly 12,000 patients over a 10-year period found a decrease in early mortality following hospital discharge after surgery for non–small cell lung cancer (NSCLC) among patients living in Medicaid-expansion states. Over the same period, researchers observed no change in mortality among patients residing in non–Medicaid-expansion states.
Leticia M. Nogueira, PhD, MPH
“Medicaid expansion under the Affordable Care Act was associated with a statistically significant decrease in 30-day postoperative mortality among individuals who were diagnosed with NSCLC,” said lead study author Leticia M. Nogueira, PhD, MPH, a principal scientist in the Surveillance & Health Equity Science Department at the American Cancer Society. “Given these results, Medicaid expansion may be an effective strategy for improving access to care and cancer outcomes among older adults who are not age-eligible for Medicare.”
As Dr. Nogueira explained, the goal of Medicaid expansion, one of the provisions of the Affordable Care Act, is to expand health insurance coverage options and improve access to care for individuals and families with an income lower than 138% of the federal poverty level. (For a family of four, this translates to approximately $36,000 per year.)
Although previous studies have shown that Medicaid expansion has led to an increase in health insurance coverage and a shift toward early-stage diagnoses in states that chose to expand Medicaid, the association between Medicaid expansion and mortality is not well characterized.2,3
According to Dr. Nogueira, evidence-based guidelines recommend surgery as the treatment for patients diagnosed with stage I, II, and III NSCLC. Most postoperative complications occur soon after surgery, she explained, with 80% of postoperative deaths happening within 30 days of surgery.
“Although patient age and comorbidity levels are strongly associated with in-hospital postoperative mortality, among patients who are discharged from the hospital after surgery, mortality is associated with access to postoperative care and health insurance coverage,” Dr. Nogueira said.
For this study, Dr. Nogueira and colleagues used the National Cancer Database, a nationwide hospital-based cancer registry that collects information on more than 70% of patients diagnosed with cancer in the United States. The researchers selected patients who were diagnosed with stage I, II, or III NSCLC and received curative-intent surgery between 2009 and 2018. Patients between the ages of 45 and 64 at the time of diagnosis were selected, because they are more likely to be diagnosed and die of NSCLC and are not age-eligible for Medicare, Dr. Nogueira said.
A total of 11,627 patients were included in the study (7,294 patients lived in Medicaid-expansion states, and 4,333 lived in non–Medicaid-expansion states). States that expanded Medicaid between 2015 and 2018 were excluded, and states that expanded Medicaid after 2018 were considered non–Medicaid-expansion states in this study. The researchers also excluded patients who had surgery during the first quarter after the Affordable Care Act, patients who had health insurance coverage other than Medicaid, and patients with key data missing from their records.
Improvement in 30-Day Postoperative Mortality
As Dr. Nogueira reported, findings from the analysis showed a significant change in postoperative mortality in states that expanded Medicaid after the Affordable Care Act. Early mortality among patients discharged from the hospital following NSCLC surgery decreased from 2.4% prior to the Affordable Care Act to 0.8% among patients in Medicaid-expansion states (1.6% decrease, P < .0001). In patients living in non–Medicaid-expansion states, however, the decrease was not statistically significant (from 2.1% to 1.6%, P = .2). This led to a statistically significant difference of 1.1 percentage points.
“Our study has several strengths,” said Dr. Nogueira. “All states in the United States were included, which allowed us to evaluate the impact of policies that are implemented at the state level such as Medicaid expansion.”
Despite the robustness of the information collected by the hospital-based registry, however, Dr. Nogueira acknowledged that the National Cancer Database does not collect information on social services provided by the hospitals. These social services could facilitate access to postoperative care, she said, especially among patients with social needs, who are the target population for Medicaid expansion.
DISCLOSURE: Dr. Nogueira reported no conflicts of interest.
1. Nogueira L, Jemal A, Han X, et al: Association of Medicaid expansion under the Affordable Care Act and early mortality following lung cancer surgery. 2021 ASCO Quality Care Symposium. Abstract 76. Presented September 24, 2021.
2. Jemal A, Lin CC, Davidoff AJ, et al: Changes in insurance coverage and stage at diagnosis among nonelderly patients with cancer after the Affordable Care Act. J Clin Oncol 35:3906-3915, 2017.
3. Han X, Yabroff KR, Ward E, et al: Comparison of insurance status and diagnosis stage among patients with newly diagnosed cancer before vs after implementation of the Patient Protection and Affordable Care Act. JAMA Oncol 4:1713-1720, 2018.
Johnie Rose, MD, PhD
Invited study discussant, Johnie Rose, MD, PhD, called the correlation between Medicaid expansion and changes in 30-day mortality a critical research question. Dr. Rose is Assistant Professor in the Center for Community Health Integration at Case Western Reserve University ...