Data Reveal Medicaid Expansion May Result in Mortality Rate Reductions for Patients With Cancer

Justin Barnes, MD

As a result of the Affordable Care Act’s Medicaid expansion, positive trends are becoming apparent regarding mortality rates for patients with cancer living in the states that have adopted Medicaid expansion. Following its 2010 enactment, the bill expanded coverage to adults under the age of 65 years with an income of up to 138% of the federal poverty level,¹ which in 2023 is $20,120 for an individual.² As of July 2023, 40 states and Washington, DC, have adopted Medicaid expansion and North Carolina has adopted but not implemented it.^2,3

Recently published data collected at the state level of 17,370 observations from the Surveillance, Epidemiology, and End Results Program and the National Center for Health Statistics databases showed that Medicaid expansion was associated with a decrease in distant stage cancer incidence (adjusted odds ratio [OR], 0.967; 95% CI, 0.943-0.992; P = .01) and cancer mortality (adjusted OR, 0.965; 95% CI, 0.936-0.995; P = .022).³

The data revealed that distant stage cancer incidence was found to mediate 58.4% of expansion-associated changes in cancer mortality overall (P = .008) which, in an interview with OncologyLive, lead study author Justin Barnes, MD, explained “is important, as it helps clarify part of the mechanism of how Medicaid expansion improves cancer outcomes. It [does this] by shifting the stage of diagnosis, at least in part, leading to fewer individuals who are diagnosed with a more advanced and potentially incurable disease.”

Barnes, who is the assistant chief resident in the Department of Radiation Oncology at the Washington University School of Medicine in St Louis, Missouri, added that “Medicaid expansion was associated with decreased distant stage cancer incidence rates and decreased cancer mortality rates, which translates to approximately 2600 averted distant stage cancer diagnoses and approximately 1600 averted cancer deaths.”

Data also revealed that statistically significant Medicaid expansion–associated decreases in cancer mortality were seen for patients with breast (OR, 0.974; 95% CI, 0.950-0.999), cervix (OR, 0.921; 95% CI, 0.869-0.975), and liver (OR, 0.934; 95% CI, 0.879-0.993) cancers, as well as for White patients (OR, 0.971; 95% CI, 0.948-0.995).

An additional study used an adjusted difference-in-differences model estimate for incidence of gastric cancer, which demonstrated that there were significantly fewer new cases of gastric cancer per year in Medicaid expansion states, at –1.6 per 1,000,000 individuals (95% CI, 0.02-0.35; P = .083).4

Shria Kumar, MD, MSCE, an assistant professor of medicine at the University of Miami Miller School of Medicine in Florida, explained in an interview with OncologyLive, that as “gastric cancer incidence expansion states had on average 1.6 fewer new cases of gastric cancer per million adults every year, that means in California there would be 32 fewer cases of gastric cancer each year and in New York state there would be 16 fewer cases.”

The model also showed that there was no significant association between Medicaid expansion and gastric cancer mortality at 0.46 cases per 1,000,000 individuals (95% CI, 0.08-0.17; P = .46), as well as esophageal cancer incidence at 0.8 cases per 1,000,000 individuals (95% CI, 0.08-0.24; P = .33), and esophageal mortality at 1.0 cases per 1,000,000 individuals (95% CI, 0.06-0.26; P = .21).

However, Kumar said that although “esophageal cancer mortality and incidence results weren’t significant, already within a few years [of having Medicaid expansion], we’re starting to see these developing trends of improvement.” Kumar also explained that regarding the gastric and esophageal data,⁴ “it’s important [to note that the] study was limited to just a few years of Medicaid expansion. I would venture to guess that with more time, we’re going to see significant differences in mortality for both cancers, as well as incidence for esophageal cancer. The reason for that is not just prevention, motivational interviewing, and so forth, but for esophageal cancer, we have screening recommendations that require access to health care.”

Outside of tumor-specific analyses, data from additional studies showed that the 2-year overall survival (OS) rate was increased by 1.5% (95% CI, 0.37-2.64) in expansion states relative to nonexpansion states for pediatric patients.¹ Additionally, the 2-year OS rate for young adults aged 18 to 39 years increased, with those in expansion (n = 213,881) states experiencing rates of 90.39% pre-expansion to 91.85% post-expansion vs 88.98% pre-expansion to 90.07% post-expansion for those in nonexpansion states (n = 131,532).⁵

Examining State Demographics

When evaluating sociodemographic characteristics from 2010 of individuals in nonexpansion states (n = 12) vs expansion states (n = 19), investigators found that 17.9% of those in nonexpansion states were Black compared with 11.0% in expansion states (P = .02). Significant differences were also observed in expansion vs nonexpansion states regarding how many individuals were diabetic (10.1% vs 9.0%; P = .01), obese (31.4% vs 27.6%; P = .01), smokers (20.0% vs 15.5%; P = .03), and living below the poverty line (17.6% vs 15.0%, P = .04), respectively.⁴

“[This is] striking, as these are states that haven’t opted into Medicaid expansion, [and] the medical conditions mentioned need health care,” Kumar said. “It’s critically important to make sure we are offering individuals who are of historically disadvantaged groups accessible and affordable medical care.”

Kumar noted that limited access to reliable health insurance leads to a lack of access to preventative services, resulting in fewer diagnoses overall and more late-stage diagnoses. “I cannot emphasize how important screening is, especially for the main luminal gastrointestinal cancers—esophagus, gastric, and colon. The difference between an early-stage diagnosis and a late-stage diagnosis is significant not just in terms of mortality but also in terms of what treatment patients receive, how expensive those treatments are, [and] what it means for surrounding friends, family, and support systems.”

Barnes echoed this explaining that, “I have unfortunately seen many patients who have delayed seeking care due to lack of insurance and worries about costs. In some cases, that’s led to more advanced cancer that is symptomatic, impacting quality of life, harder to treat possibly requiring longer and more intensive and toxic treatments, and [their disease is] less likely to be cured. With more patients with Medicaid coming in the door, we are hopefully avoiding some of those more advanced presentations and can get patients the treatment they need.”

Medicaid Disenrollment

As preventative measures such as screening remain crucial, additional challenges have arisen as individuals may face Medicaid re-enrollment difficulties in the future. Because of the COVID-19 pandemic, Congress enacted the Families First Coronavirus Response Act, which required that Medicaid keep individuals continuously enrolled;⁶ however, as of April 1, 2023, Congress declared that Medicaid programs must go back to federal rules.⁷ With this, millions of patients had their coverage affected.

“In the past few months, we’ve seen over 5 million Medicaid enrollees who have been disenrolled with the unwinding of the public health emergency, which previously allowed individuals who qualify for Medicaid to remain continuously enrolled,” Barnes said. “There are 5 million so far, and an additional 10 million [individuals] are projected to be disenrolled over the next several months. This could have disastrous consequences from a cancer perspective.”

However, Barnes explained that “some of this could be mitigated through consideration of Medicaid expansion in those 10 states that haven’t yet expanded, especially because approximately a half million [individuals] who will lose coverage live in those states. They are projected to fall into a coverage gap, which means they live in these states, don’t have access to expanded Medicaid eligibility, and their income is too high to qualify for Medicaid but not high enough to qualify for subsidies through the marketplace. We need to figure out how to best support the disenrolled individuals and reduce some of the administrative disenrollments for [those] who are still eligible for Medicaid.”

Barnes noted that resources such as the American Cancer Society Cancer Action Network, which he regularly is in touch with, help him find ways to advocate for patients in Missouri. He also highlighted that the American Society of Clinical Oncology (ASCO) and American Society for Radiation Oncology (ASTRO) will often work to develop initiatives on proposed legislation or issues facing care on their platforms. These proposals also allow individuals to connect with state representatives, and following determination of the proper representative, ASCO/ASTRO will provide a letter template with relevant data written out, allowing for a convenient direct message to be sent to the representative.

“For Medicaid expansion enrollment, you need state legislature as well as governor authorization,” Kumar said. “[In] the years since we conducted our study, more states have opted into Medicaid expansion, and a lot of that has been because of health care advocacy groups. They have been a big force in ensuring more individuals get access to health care.”

Barnes said the message is simple: “Medicaid expansion can save lives and prevent cancer deaths. When we think about our health care system on a state or national level, these data add to an ever-growing body of evidence that increasing insurance coverage, especially to more vulnerable populations such as those who are eligible for Medicaid, can increase access to care and improve cancer outcomes.”

References

1. Hotca A, Bloom JR, Runnels J, et al. The impact of Medicaid expansion on patients with cancer in the United States: a review. Curr Oncol. 2023;30(7):6362-6373. doi:10.3390/curroncol30070469
2. Status of state Medicaid expansion decisions: interactive map. Kaiser Family Foundation. July 27, 2023. Accessed September 8, 2023. https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/
3. Barnes JM, Johnson KJ, Osazuwa-Peters N, Yabroff KR, Chino F. Changes in cancer mortality after Medicaid expansion and the role of stage at diagnosis. J Natl Cancer Inst. 2023;115(8):962-970. doi:10.1093/jnci/djad094
4. Niroomand E, Kumar SR, Goldberg D, Kumar S. Impact of Medicaid expansion on incidence and mortality from gastric and esophageal cancer. Dig Dis Sci. 2023;68(4):1178-1186. doi:10.1007/s10620-022-07659-6
5. Ji X, Shi KS, Mertens AC, et al. Survival in young adults with cancer is associated with Medicaid expansion through the Affordable Care Act. J Clin Oncol. 2023;41(10):1909-1920. doi:10.1200/JCO.22.01742
6. Tolbert J, Ammula M. 10 things to know about the unwinding of the Medicaid continuous enrollment provision. Kaiser Family Foundation. June 9, 2023. Accessed September 8, 2023. https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-the-unwinding-of-the-medicaid-continuous-enrollment-provision/
7. Eligibility unwinding. New Jersey Department of Human Services. Accessed September 8, 2023. https://nj.gov/humanservices/dmahs/staycoverednj/unwinding/