Medicaid Expansion May Have Survival Benefits for Men with NSCLC

A study published in JAMA Oncology suggested that Medicaid expansion could have survival benefits for men with non-small cell lung cancer (NSCLC), which could possibly be attributable to improved insurance coverage and early-stage diagnosis. 

However, this same association pattern was not observed for women. 

“Advances in lung cancer care have improved survival, but this has not reached all socioeconomic groups,” the authors wrote. “Insurance status affects access to early detection and stage-appropriate cancer treatments, which drive survival outcomes.”

Using the Surveillance, Epidemiology, and End Results (SEER) database, researchers identified 55,526 men (uninsured, n = 4,492 [8.1%]) and 45,701 women (uninsured, n = 2,973 [6.5%]) aged 20 to 64 years who were diagnosed with NSCLC as a first primary malignant neoplasm from 2007 through 2016. Notably, 4 participating states did not expand Medicaid from 2014 through 2016, while 9 did. 

Overall, the distributions of covariates were somewhat different between those in Medicaid expansion states and those in nonexpansion states. Compared with patients in Medicaid nonexpansion states, those in Medicaid expansion states had a similar age distribution, were more likely to be female, Hispanic, or Asian, married, and live in the least socioeconomically deprived counties, and were less likely to be black and live in rural counties. 

The median follow-up was 67 months for pre-Affordable Care Act groups and 12 months for post-Affordable Care Act groups. 

The unadjusted 2-year survival rates in men before and after Medicaid expansion increased from 32.0% to 37.0%, while survival rates in the nonexpansion states increased from 27.8% to 30.4%. Moreover, the unadjusted and multivariable-adjusted increases in 2-year survival rates for men post-Affordable Care Act were 2.4 (95% CI, 1.1-3.8; P = .02) and 2.0 (95% CI, 0.2-3.7; P = .03) percentage points higher in expansion states than in nonexpansion states, respectively. 

For women, the unadjusted 2-year survival rates after Affordable Care Act implementation showed similar increases in expansion (45.1% to 49.7%) and nonexpansion (39.3% to 44.2%) states. However, there were no significant differences in survival changes. 

“We observed greater reductions in the percentages of uninsured cases and larger increases in the percentages of early-stage diagnoses among men in expansion vs nonexpansion states after ACA implementation,” the authors wrote. “By contrast, the changes in these 2 measurements for women did not differ significantly.” 

Limitations for the study included the lack of some prognostic factors related to NSCLC, such as comorbidities, and a short-term follow-up after Medicaid expansion. 

“Studies have reported that Medicaid expansion reduced uninsured rates among non-older adult patients with cancer but did not increase the percentage of early-stage lung cancer diagnoses. These analyses were limited by 1-year data after (Affordable Care Act) implementation and did not assess the contribution of Medicaid expansion to lung cancer survival,” the authors wrote. “The availability of 3-year post-(Affordable Care Act) SEER data allowed us to examine the short-term survival benefits of Medicaid expansion.”

References:

Liu Y, Colditz GA, Kozower BD, James A, Greever-Rice, Schmaltz C, Lian M. Association of Medicaid Expansion Under the Patient Protection and Affordable Care Act With Non-Small Cell Lung Cancer Survival. JAMA Oncology. doi:10.1001/jamaoncol.2020.1040.