Studies showed that racial minorities experience disparities in access to cancer treatment and survival. 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 provide coverage to low-income individuals who lacked health insurance.
Findings from a new study showed that Medicaid expansion was associated with a greater reduction in 2-year mortality rates among Black patients with gastrointestinal cancers living in states with Medicaid expansion compared with those living in states without Medicaid expansion. Existing racial disparities in mortality remained the same or worsened for patients living in states without Medicaid expansion, but in almost all cases, they were mitigated for those living in states with Medicaid expansion. These results were presented during the 2023 ASCO Annual Meeting by Manisundaram et al (Abstract 6546).
In this study, the researchers used the National Cancer Database 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 Medicaid expansion (from 2009–2013) and after expansion (from 2014–2019). 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.
The researchers included 86,052 patients for their analysis, including 19,188 patients with pancreatic cancer, 60,404 patients with colorectal cancer, and 6,460 patients with gastric cancer. They found that 2-year mortality decreased among Black patients with pancreatic cancer residing in Medicaid expansion states (–11.8%) compared with non–Medicaid expansion states (–2.4%; DID = –9.4%, P < .001).
In the Medicaid expansion states, there was a greater absolute decrease in 2-year mortality postexpansion for patients with colorectal cancer (–4.9% for Black patients and –6% for White patients) compared with non–Medicaid expansion states (–2% for Black patients and –1.8% for White patients; DID = –2.9% for Black patients and –4.2% for White patients). Among patients with stage IV colorectal cancer, there was a net increase in the rates of surgery in the Medicaid expansion states compared with the non–Medicaid expansion states: –13% vs –5.2%, respectively (DID = –7.7% P = .07).
Among patients with gastric cancer, Black patients in Medicaid expansion states experienced a marked reduction in mortality compared with those in non–Medicaid expansion states (DID = –7.7%, P = .07). Both Black and White patients with stage III to IV pancreatic cancer saw an increase in the receipt of chemotherapy in Medicaid expansion states following expansion (DID = 3.7%, P = .28 for Black patients and DID = 2.7%, P = 0 for White patients).
A greater increase in receipt of chemotherapy was observed among Black patients with stage IV gastric cancer in Medicaid expansion states than in non–Medicaid expansion 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 non–Medicaid expansion states. Existing racial disparities in mortality remained the same or worsened in non–Medicaid expansion states, but in almost all cases, [they] were mitigated in Medicaid expansion states following Medicaid expansion,” concluded the study authors.
Reducing Health Disparities in Cancer Care
In a press briefing held by ASCO to present this study’s findings, lead author of the study Naveen Manisundaram, MD, a physician in the Department of Neuroscience at Baylor College of Medicine in Houston, 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.”
In her analysis of the study’s findings, moderator of the press briefing Julie R. Gralow, MD, FACP, FASCO, Chief Medical Officer and Executive Vice President of ASCO, noted that a strength of the study is that 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 we have the expanded states and those that didn’t [expand Medicaid]. [Dr. Manisundaram and colleagues] were able to show in particular that Black patients [benefited] from Medicaid expansion and showed 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 states have just expanded [Medicaid] in 2023, [but] it hasn’t actually gone into effect yet, and so we’ve got about 10 more states now [with 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 National Institutes of Health. For full disclosures of the study authors, visit coi.asco.org.The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.