Jingxuan Zhao, MPH

A study investigating the association between state Medicaid income eligibility limits and long-term survival among newly diagnosed patients with cancer has found that patients living in states with lower Medicaid income eligibility limits had worse long-term survival compared with patients living in states with higher income eligibility limits. The research also determined that this association was consistent across a variety of cancers and for patients with either early- or late-stage disease at diagnosis.¹ The study by Jingxuan Zhao, MPH, Senior Associate Scientist at the American Cancer Society, and colleagues was presented during the 2021 ASCO Annual Meeting.

Medicaid, a public insurance program that provides health-care coverage for some low-income people, families and children, pregnant women, the elderly, and people with disabilities, is funded jointly by the federal government and the states. Income eligibility and benefits often vary widely from state to state. Medicaid expansion, which was implemented in 2014 under the Affordable Care Act (ACA), helped states expand Medicaid coverage for eligible adults with incomes up to 138% of the federal poverty level (about $15,800 for a single adult in 2014). By August 2021, only 38 states (plus the District of Columbia) have adopted Medicaid expansion, and 12 states have not.²

Previous research showed that low-income adults in states with expanded Medicaid coverage have improved health outcomes compared with their counterparts in states without Medicaid expansion.³ Less is known about the effects of Medicaid expansion under the ACA on long-term survival following cancer diagnosis because these data are not yet available. This study used historic data on Medicaid income eligibility limits and long-term survival among patients newly diagnosed with cancer to provide context as these data accumulate post-ACA.

Study Methodology

The researchers used data from the National Cancer Database to identify 1,426,657 adults (aged 18 to 64 years) who were newly diagnosed with 17 common cancers between 2010 and 2013. They categorized states’ Medicaid income eligibility limits as ≤ 50%, 51%–137%, and ≥ 138% of the federal poverty level. Survival time was measured within stage from the date of diagnosis through December 31, 2017, for up to 8 years of follow-up.

Multivariable Cox proportional hazard models with age as time scale were used to assess associations of eligibility limits and stage-specific survival, controlling for gender, race/ethnicity, metropolitan statistical area, number of comorbidities, year of diagnosis, facility type, and the random effect of state of residence.

Key Results

The researchers found, among newly diagnosed patients with cancer aged 18 to 64, 22.0%, 43.5%, and 34.5% resided in states with Medicaid income eligibility limits ≤ 50%, 51%–137%, and ≥ 138% of the federal poverty level, respectively. Compared with patients living in states with Medicaid income eligibility limits ≥ 138% of the federal poverty level, patients living in states with Medicaid income eligibility limits ≤ 50% and 51%–137% of the federal poverty level were more likely to have worse survival for most cancers in both early and late stages.

The highest hazard ratios were observed among patients living in states with eligibility limits ≤ 50% of the federal poverty level (P trend < .05). For example, for women with early-stage breast cancer, the hazard ratios were 1.31 (95% confidence interval [CI] = 1.18–1.46) and 1.17 (95% CI = 1.06–1.30) for patients living in states with Medicaid income eligibility limits ≤ 50% and 51%–137% compared to those living in states with Medicaid income eligibility limits ≥ 138% of the federal poverty level.

“Based on historical data, lower Medicaid income eligibility limits were associated with worse long-term survival within stage, with variation below the Medicaid eligibility threshold that was implemented by the Affordable Care Act. Medicaid expansion or other policies that increase the Medicaid income eligibility limit may improve survival following cancer diagnosis in states with Medicaid income eligibility lower than the ACA-recommended threshold,” concluded the study authors.

Ensuring Equal Cancer Care for All Patients

“[This] study clearly shows evidence that state expansion of Medicaid income eligibility limits is associated with better long-term survival in newly diagnosed patients,” commented Immediate Past President of ASCO Lori J. Pierce, MD, FASTRO, FASCO, during a press briefing highlighting this study abstract. “This is particularly relevant since there are such variable limits among states regarding Medicaid expansion with the Affordable Care Act.”

Lori J. Pierce, MD, FASTRO, FASCO

Dr. Pierce continued: “I think these data can be used to encourage those states that have chosen not to expand Medicaid coverage to strongly reconsider since people who are uninsured are very likely to forgo screening, so you miss the detection of early lesions, when cure can be far more likely. Those who are uninsured are unlikely to receive cancer care, and for those who are able to start cancer treatments, they are unlikely to complete their cancer care. Equity of care is very, very critical.”

Next Steps

The researchers next plan to use the National Cancer Database to investigate the association between historical Medicaid income eligibility limits and other outcomes, such as stage at diagnosis and receipt of cancer treatment, and whether outcomes differ by race/ethnicity and area-level poverty. Additional analysis may also include the association between historical Medicaid income eligibility limits and access to health care and affordability among cancer survivors. 

DISCLOSURE: Dr. Zhao reported no conflicts of interest. Dr. Pierce holds stock or other ownership interests in PFS Genomics; holds intellectual property in PFS Genomics and UpToDate; and has had uncompensated relationships with Bristol Myers Squibb and Exact Sciences.

REFERENCES

1. Zhao J, Han X, Nogueira L, et al: Association of state Medicaid income eligibility limits and long-term survival after cancer diagnosis in the United States. 2021 ASCO Annual Meeting. Abstract 6512. Presented June 4, 2021.

2. Medicaid and CHIP Payment and Access Commission: Overview of the Affordable Care Act and Medicaid. Available at www.macpac.gov/subtopic/overview-of-the-affordable-care-act-and-medicaid. Accessed August 20, 2021.

3. Ollove M: Medicaid expansion states see better health outcomes, study finds. PEW Stateline Update, January 7, 2020. Available at www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2020/01/07/medicaid-expansion-states-see-better-health-outcomes-study-finds. Accessed August 20, 2021.