Cancer Death Rates Dropped More in States That Expanded Medicaid Under Affordable Care Act

The death rate from cancer dropped more in states that expanded Medicaid coverage than those that didn’t following the passage of the Affordable Care Act (ACA) of 2010, according to results of a nationwide study presented during a 2020 ASCO Virtual Scientific Program press briefing.

Authors said the study was the first of its kind to examine cancer mortality in the wake of the act, under which states are allowed to expand Medicaid coverage to a larger swath of people with low incomes with the help of federal funding. While cancer death rates fell across the board during the period studied, researchers found that mortality rates declined from baseline by 29% in states that expanded Medicaid vs. 25% in those that did not.

"This is the first study to show the benefit of Medicaid expansion on cancer death rates on a national scale,” lead study author Dr. Anna Lee, a radiation oncology fellow at Memorial Sloan Kettering Cancer Center in New York, said in an ASCO-issued press release. “We now have evidence that Medicaid expansion has saved the lives of many people with cancer across the United States.”

The researchers pulled their data from the National Center for Health Statistics, maintained by the Centers for Disease Control, which captures all U.S. deaths from cancer. After establishing baseline trends from 1999 to 2017, they compared age-adjusted cancer death rates between 2011 and 2013, prior to full state expansion, with rates from 2015 to 2017, the period following expansion, for states that adopted Medicaid expansion and those that did not.

During the time period analyzed, 27 states plus the District of Columbia had adopted Medicaid expansion, while 23 states had not.

The study included people under age 65, as those older are eligible for Medicare. About 30% of all cancer deaths occur in patients under age 65.

In states that expanded Medicaid, the 29% decline brought the cancer death rate from a baseline 65.1 to 46.3 per 100,000 individuals between 1999 and 2017, while the 25% drop in states that did not expand brought the rate from 69.5 to 52.3 per 100,000 in the same period. When looking at the rate changes that occurred after expansion became an option in 2014, Lee said one example is that the states that broadened Medicaid coverage saw a combined 785 fewer cancer deaths in 2017. She and her colleagues projected that an additional 589 cancer deaths would have been prevented that year if the states that didn’t expand Medicaid had done so.

The researchers also looked at changes in subgroups of the population after the passage of the ACA. While the cancer mortality rate improved substantially for black patients during the study period, no additional improvement was seen for this group in states that expanded Medicaid. However, age-adjusted cancer mortality overall was consistently worse for black patients in states without expansion than in states with expansion (58.5 vs. 63.4 per 100,000 for the expansion and non-expansion states, respectively).

Hispanic patients, on the other hand, had marked drops in cancer mortality in expansion vs. non-expansion states, although researchers noted significant variation in these numbers from year to year.

“There is a greater Hispanic population in states that have adopted Medicaid expansion, and they have almost three times the un-insurance rate as white adults,” study senior author Dr. Fumiko Chino, a radiation oncologist at MSK, said in a press release. “Our research shows that Hispanic patients with cancer may have benefited the most because they had the most to gain.”

For the study analysis, the researchers used a statistical technique called difference-in-differences. They looked at the change within each group from baseline and then compared the change between the two groups. The method was used to mitigate the effects of population differences and other geographical differences in access to health care.

Comparing the mortality changes before and after ACA expansion, the difference-in-differences was -1.1 and -0.6 per 100,000 for expansion and non-expansion states, respectively.

“We compared the change in mortality before and after the ACA and saw a greater change in expanded states,” Lee said. “There was an overall difference of -0.5 per 100,000 people, which is the potential true benefit of Medicaid expansion on a population level.” The cancer mortality benefit in Hispanic patients was -2.1 per 100,000 people, she added.

“For a policy to have an impact in such a short amount of years shows that it’s pretty impactful,” she said.

As new annual data becomes available through the National Center for Health Statistics, the researchers plan to add to their analysis. In addition, Lee said that future studies are needed “on how national programs and policies can continue to improve access to care and decrease health disparities.”

Granting states permission to expand Medicaid coverage to more people was one of the key components of the ACA, also known as Obamacare, ASCO noted in a press release. Medicaid is administered by the states and provides health care coverage for eligible people with disabilities or very low incomes. Many states formally adopted Medicaid expansion in January 2014; those states that participated saw large increases in Medicaid enrollment, ASCO stated, including people with incomes near the poverty level who were newly eligible as well as those who had been eligible but had not enrolled previously.

“Medicaid expansion increased insurance coverage to 20 million people (who didn’t have it before), so that in itself means patients getting access to care,” Lee said. “Also, we’re seeing studies showing that having access (to health care) is associated with more timely treatment and … having treatment options for cancer. That’s very important, because having multiple options means you could get the best care available, and that impacts outcomes.”