CHICAGO—Medicaid expansion as part of the Affordable Care Act (ACA) improved African-American cancer patients' receipt of timely treatment and reduced racial disparities in access to care. After Medicaid expansion, African-American patients had the greatest rate of improvement in receiving care within 30 days of diagnosis as compared with white patients.
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, according to a new analysis of electronic health records (EHR) of more than 30,000 patients.
“Racial disparities in cancer-related care and outcomes exist. Timely cancer treatment is patient-centered and may improve clinical outcomes,” said senior 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 the Yale Cancer Center. “Many studies have described racial disparities that exist in cancer care, but few have shown what types of interventions improve health equity. We now have evidence that Medicaid expansion can mitigate certain health disparities. We also know that 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.”
Davidoff presented the results of the phase III randomized controlled trial at the 2019 ASCO annual meeting (Abstract LBA1).
Two of the key components of the ACA, which became law in 2010, were granting states permission to expand Medicaid coverage and provide subsidies for people to buy private insurance if they did not qualify for Medicaid. States were granted Medicaid expansion starting in January 2014, and those states that participated saw large increases in Medicaid enrollment, including people newly eligible as well as those who had been eligible, but had not enrolled previously. Some states expanded Medicaid after the 2014 implementation of the ACA, and additional states have expanded Medicaid over time.
About the Study
The researchers looked at de-identified health records from Flatiron Health's EHR-derived database. This database holds information on 2.2 million patients diagnosed with cancer who received care at 280 community-based cancer clinics or academic medical centers, representing 800 sites of care nationwide. This analysis included data from 30,386 patients, ages 18-64, diagnosed with advanced or metastatic solid tumors (non-small cell lung cancer, breast, urothelial, gastric/esophageal, colorectal, renal cell, prostate, and melanoma) through the period from January 2011 through January 2019.
Patients were randomly assigned to either an expanded cohort or not expanded cohort based on whether the state where they lived had adopted and implemented a Medicaid expansion at the time of their diagnosis. Linked data from the Kaiser Family Foundation were used to assign expansion status.
Investigators determined whether patients received treatment within 30 days of an advanced cancer diagnosis. Time to treatment was selected as the primary outcome.
The researchers tested whether Medicaid expansion was associated with reduction of racial disparities, after accounting for age, sex, cancer type, cancer stage, state of residence, time of diagnosis, unemployment rate, and the type of practice setting where treatment was received.
Overall, the study did not find a statistically significant increase in timely treatment after Medicaid expansion for patients. The researchers focused on whether outcomes were different between whites and African-Americans because previous studies had shown African-American patients experienced the greatest burden of racial disparity.
Prior to Medicaid expansion, African-American patients were 4.8 percentage points less likely to receive timely treatment as compared with white patients. Medicaid expansion was most beneficial for African-Americans when it came to timely treatment, with a 6.1 percentage point improvement as compared with a small, statistically insignificant 2.1 percentage point increase among white patients.
Racial disparities seen without Medicaid expansion all but disappeared after expansions were implemented—there was no significant difference (0.8%) in timely receipt of treatment between African-American and white patients under Medicaid expansion, Davidoff explained.
“African-American patients benefited more than white patients with expansion,” she stated. “Medicaid expansion was associated with reduced racial disparities in timely cancer treatment. This extends prior evidence regarding effects of ACA expansions on insurance coverage and general access for cancer patients. National healthcare coverage policy may reduce disparities in cancer care.”
The researchers 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 the City of Hope, commented: “Earlier this year, ASCO identified disparities, especially racial disparities, in access to care as a priority area of research for accelerating progress against cancer. This study is a major step forward in developing our understanding of this complex issue so we can identify solutions to address it.
“This is the best evidence to date that a specific policy change can affect treatment equity. Those patients who were falling behind had more benefit. To see the disparity go away is impressive,” he concluded.
Mark L. Fuerst is a contributing writer.