Medicaid Expansion Improved Racial Disparities in Cancer Care

CHICAGO-The Affordable Care Act (ACA) may help improve outcomes for a large number of cancer patients by taking down significant barriers to timely cancer treatment. Researchers are reporting that previous racial disparities in timely cancer treatment between African American and white patients practically disappeared in states where Medicaid access was expanded under the ACA (abstract LBA1). These results were presented at the 2019 American Society of Clinical Oncology (ASCO) Annual Meeting, held May 31–June 4 in Chicago. Investigators at Yale University analyzed electronic health records of 30,386 patients (18 to 64 years old) and found that African American patients had the greatest rate of improvement in receiving cancer care within 30 days of diagnosis as compared with white patients after Medicaid expansion.

“The difference…between black patients and white patients was substantial and significant,” said study author Amy J. Davidoff, PhD, MS, senior research scientist in health policy and management at the Yale School of Public Health and a member of Yale Cancer Center in New Haven, Connecticut.

The findings showed that Medicaid expansion was most beneficial for African Americans when it came to timely treatment, with a 6.1% improvement as compared with a small and statistically insignificant 2.1% point increase among white patients. Racial disparities seen prior to Medicaid expansion all but disappeared after expansions were implemented, according to the researchers. They found there were no significant differences in timely receipt of treatment between African American and white patients after Medicaid expansion.

Davidoff said that the uncertainty about having health insurance, especially for someone newly diagnosed with cancer, can make a big difference in getting appropriate care in a timely manner. She noted that many studies have described racial disparities that exist in cancer care, but few have shown what types of interventions improve health equity. Davidoff said these new findings provide strong evidence that Medicaid expansion can mitigate certain health disparities.

The ACA became law in 2010 and it granted states permission to expand Medicaid coverage to more individuals and to provide subsidies for individuals to buy private insurance if they did not qualify for Medicaid. Davidoff said 33 states and Washington, DC have implemented Medicaid expansions as of January 2019. The researchers looked at de-identified health records from Flatiron Health’s electronic health record–derived database from 800 sites of care nationwide. The researchers looked at data on 2.2 million patients diagnosed with cancer who received care at 280 community-based cancer clinics or academic medical centers. This analysis included data from 30,386 patients who were diagnosed with advanced or metastatic solid tumors (non–small-cell lung, breast, urothelial, gastric/esophageal, colorectal, renal cell, and prostate cancers, as well as melanoma) between January 2011 and January 2019.

For this investigation, the patients were grouped based on whether their state had expanded and implemented a Medicaid expansion at the time of their diagnosis. The investigators picked time to treatment as the primary outcome, because it is clinically meaningful, related to overall survival, and it is patient centered. They examined whether Medicaid expansion was associated with reduction of racial disparities, while adjusting for age and other factors. They used regression model covariates that included race (white, African American, Asian, and other race), age, sex, practice type, cancer type, stage of disease, employment status, using time, and state fixed-effects.

The researchers report that prior to Medicaid expansion, African American patients were 4.8% less likely to receive timely treatment as compared with white patients. Researchers did not find a statistically significant increase in timely treatment after Medicaid expansion for patients overall. However, they found that the expansion was associated with a significant benefit for African Americans compared with white patients (6.9% vs 1.8%).

The investigators are developing models to predict what treatment outcomes would be if there was no Medicaid expansion as compared with expansion in all states. ASCO Expert William Dale, MD, PhD, Arthur M. Coppola Family Chair in Supportive Care Medicine at City of Hope, who commented on the study at the news briefing, said that earlier this year ASCO identified racial disparities in access to care as a priority area of research for accelerating progress against cancer. He noted that this study is a major step forward in developing a better understanding of this complex issue and in helping to identify solutions to address it. “This work is to be commended. I think it is some of our best evidence we’ve had to date that a specific policy change can have an impact on disparities in health equity, particularly with regard to the timing of treatment,” said Dale.