Medicaid expansion associated with earlier-stage cancer diagnoses
Changes to increase eligibility for Medicaid under the Affordable Care Act have seen patients more likely to have healthcare coverage. Consequently, diagnoses of breast, colon and lung cancer have been made at earlier stages, associated with improved prognosis.
A cross-sectional analysis comparing insurance status, cancer stage at diagnosis and timely treatment across states found that where Medicaid eligibility had been expanded, patients were more likely to have medical insurance, and breast, colon and lung cancer were more often diagnosed at early stages. Time to treatment, which has been raised as a concern by opponents of Medicaid, was found to be unchanged in association with Medicaid expansion.
The study, published in JAMA Network Open, was conducted by researchers at the University of Pennsylvania (PA, USA). The authors analyzed de-identified patient data from across the USA, including 925,543 patients aged 40–63 years from 2011 to 2016, observing changes from 2014 when some states raised the maximum income threshold for receipt of Medicaid.
Stage I diagnoses of lung, breast and colorectal cancers increased in both expansion and non-expansion states (by 1.8% and 1.4%, respectively), however a difference-in-difference analysis revealed a significant advantage to states which had expanded access to Medicaid. The increase in Stage I diagnoses saw a corresponding decrease in Stage IV detection, a difference generally associated with improved prognosis in cancers.
Furthermore, expansion states saw a decrease in uninsured patients, with a rise in the proportion of patients insured on Medicaid. The authors pointed out the importance of these two factors, stating: "Because lack of insurance is associated with poor health outcomes and because stage is one of the most potent factors associated with survival for patients with cancer, our findings suggest definitive and persistent benefit 3 years after [Affordable Care Act] implementation to non-elderly patients newly diagnosed with breast, colon and non-small-cell lung cancer residing in states that adopted Medicaid expansion."
In an accompanying commentary from researchers at Stanford University (CA, USA), the lack of change in time to treatment was highlighted: “…there was no difference in declining percentage of patients treated within 30 and 90 days between Medicaid expansion and non-expansion states. This is somewhat puzzling, given the increased early-stage detection, and is especially worthy of further analysis because increased [time to treatment] is associated with increased mortality.”
The study authors, however, suggested the time-to-treatment results may reflect positively on Medicaid, given previous studies that suggested an unintended consequence may be lengthened wait times.
Lead author Samuel Takvorian (University of Pennsylvania) stated: "Despite concerns that coverage expansions would result in longer wait times for treatment, my colleagues and I found no evidence that Medicaid expansion worsened access to timely cancer-directed therapies."
Takvorian SU, Oganisian A, Mamtani R et al. Association of Medicaid expansion under the Affordable Care Act with insurance status, cancer stage, and timely treatment among patients with breast, colon, and lung cancer. JAMA Netw. Open. doi:10.1001/jamanetworkopen.2019.21653 (2020) (Epub ahead of print); Fu S, Rose L, Knowlton L. The Affordable Care Act and insurance status, stage, and timely treatment among patients with cancer. JAMA Netw. Open. doi:10.1001/jamanetworkopen.2019.21690 (2020) (Epub ahead of print); https://ldi.upenn.edu/healthpolicysense/medicaid-expansion-s-effects-patients-newly-diagnosed-common-screenable-cancers