States With Medicaid Expansion Experience Improved Cancer Care Delivery

Expanded access to Medicaid may yield improvements in the delivery of cancer care, according to findings from 2 presentations discussed at the 2022 ASCO Quality Care Sympoisum.^1,2

Xuesong Han, PhD, director of surveillance and health services research with the American Cancer Society, and adjunct professor of the Department of Epidemiology at the Rollins School of Public Health of Emory University; and Justin Michael Barnes, MD, MS, a radiation oncology resident at Washington University School of Medicine in St Louis, both presented on the effects of Medicaid on cancer care as part of a discussion on Health Care Access, Equity and Disparities.

Han’s presentation underscored the relationship between Medicaid expansion and increased palliative care use among patients with advanced cancer and Barnes’ presentation showed that expansion may be linked to decreases in mortality rates in certain populations.

Medicaid and Palliative Care

Xuesong Han, PhD

Practice guidelines recommend that all patients with advanced cancer be referred for palliative care; however, actual use of palliative services is low, according to Han. Current barriers to palliative care services include a lack of knowledge surrounding the availability and benefit of palliative care, workforce shortages, and insufficient organization capacity. Investigators have also hypothesized that lack of insurance may represent another key barrier to accessing this type of care.¹

The Affordable Care Act has increased access to cancer care and investigators sought to identity how expanded insurance access would relate to palliative care use in the United States. They analyzed the records of 685,781 patients included in the National Cancer Database. These patients were between the ages of 18 to 64 years and were newly diagnosed with a primary stage IV cancer. Investigators looked at whether patients received palliative care and their states’ Medicaid expansion status both pre-expansion (2010-2013) and post-expansion (2014-2019).

In Medicaid-expansion states, the percentage of patients with advanced cancer who received palliative services increased from 17.0% pre-intervention to 18.9% post-intervention, the difference was 1.9% (1.7%-2.1%). By comparison, in nonexpansion states, the percentage of patients receiving palliative care changed from 15.7% to 16.7%, representing a 1.0% change (0.6%-1.3%). In the adjusted model, the difference-in-differences was determined to be 1.4% (1.0%-1.8%).

Interestingly, the percentage increase varied among different cancer types. Higher rates of palliative care use were seen in cancer types with historically worse prognoses post intervention, including colorectal (5.1%) and pancreatic cancers (3.6%).

“Among individuals diagnosed with stage IV cancer, Medicaid expansion was associated with increases in receipt of palliative care, although overall usage was low,” Han said. “The association was strongest among prevalent cancer types with poor prognosis and/or serious symptom burden.”

In addition, Han stated that the expansion of Medicaid coverage can be a policy strategy to increase use of guideline-based palliative care. At the same time, she acknowledged that it is possible that differential state health policies could result in a widened disparity in palliative care receipt geographically.

Medicaid and Mortality Rates

Justin Michael Barnes, MD, MS

In a presentation given by Barnes, Medicaid expansion was linked to decreased distant-stage incidence and cancer mortality. Specifically, expanded Medicaid was associated with an adjusted odds ratio (OR) of 0.967 (P = .01) for distant stage incidence, 0.965 (P = .022) for mortality without stage, and 0.969 (P =.033) for mortality with stage. The percentage decrease of distance-stage incidence was 12% (P = .041).²

According to investigators, these numbers translate into 2612 averted distant-stage cancer diagnoses, and 1031 averted cancer deaths per year in Medicaid-expanded states. Although these numbers may be relatively small, they are statistically significant, Barnes said.

Of note, investigators also found that these effects were pronounced among the White population, although they were minimal for Black patients with cancer. The White population accounted for 75% of the percentage change in distant-stage diagnoses (P = .009), signifying that other factors besides insurance coverage are serving as structural barriers to care.

Previous studies have suggested that Medicaid expansion is tied to improved early cancer diagnoses and increased 2-year overall survival rates.2 It is not yet known if the early detection or the improved access to treatment is responsible for the improved OS rates. However, investigators sought to expand upon these findings and understand how Medicaid expansion affects patients across other domains.

Barnes' team pooled data from the National Program of Cancer Registries and Surveillance, Epidemiology, and End Results Program to evaluate cancer incidence rates by stage, and the National Center for Health Statistics to assess cancer mortality rates. These databases included patients from all 50 states, with ages ranging from 20 to 64 years. Data were stratified by year, age, sex, and race.

“Medicaid expansion through improved access to care led to fewer distant-staged cancer diagnoses, essentially causing a shift in stage of diagnosis, [and] ultimately leading to fewer cancer deaths,” Barnes said. “[However,] it is important to note that there are likely other mediators at play which we feel are likely related to access to timely and quality treatment.”

References

1. Han Z, Shi K, Zhao J, Nogueira, Parikh RV, Jemal A, Yabroff RR. Association of the Affordable Care Act Medicaid expansion and receipt of palliative care among individuals newly diagnosed with advanced stage cancers. J Clin Oncol. 2022;40(suppl 28):73. doi:10.1200/JCO.2022.40.28_suppl.073
2. Barnes JM, Johnson KJ, Osazuwa-Peters N, Chino F. Changes in cancer mortality rates after Medicaid expansion under the Affordable Care Act and the role of changes in stage at diagnosis. J Clin Oncol. 2022;40(suppl 28):74 doi