番茄社区

CHICAGO – States that adopted Medicaid expansion under the Affordable Care Act (ACA) have virtually wiped out racial differences in the time between diagnosis with metastatic cancer and treatment initiation, compared to differences before ACA implementation, researchers reported here.

Before Medicaid expansion began in 2014 and in 17 states that decided not to accept it, 48.3% of whites diagnosed with metastatic disease began treatment within 30 days compared with 43.5% of African Americans – a 4.8% difference (P<0.001), reported Amy Davidoff, PhD, of the Yale School of Public Health, New Haven, Connecticut.

In states that expanded Medicaid, meanwhile, 50.3% of whites and 49.6% of blacks (P=0.63) received cancer treatment within 30 days of diagnosis, she said at the American Society of Clinical Oncology's annual meeting.

The reduction in disparity with Medicaid expansion of 4 percentage points was statistically significant (P=0.042), Davidoff said at a press briefing.

Lead author of the study, Blythe Adamson, PhD, senior qualitative scientist at Flatiron Health, New York City, explained that the group accessed 2.2 million individuals' health records to identify patients ages 18 to 64 years diagnosed with advanced or metastatic cancer including non-small-cell lung cancer, breast cancer, urothelial cancers, colorectal cancer, renal cell cancer, prostate cancer, and melanoma from January 2011 to the end of 2018. The de-identified patients were coded as to whether they lived in a state where Medicaid expansion had been approved.

"We estimated Medicaid expansion-related changes in the rate of 'timely treatment,' an outcome defined as first-line treatment start within 30 days of advanced or metastatic diagnosis," Adamson said.

The analysis included 18,678 individuals who lived in states that had not expanded Medicaid and 11,708 individuals in expansion states. Just under half of patients in expansion and non-expansion states alike were men. In non-expansion states, 73.3% of the patients identified as white and 14.6% as black. In the expansion states, the corresponding percentages were 70.3% white and 8.7% black. About 35% of the patients were diagnosed with lung cancer, 21% with colon cancer, and another 21% with breast cancer.

Davidoff told 番茄社区, "Our study extends prior evidence regarding effects of the Affordable Care Act expansions on insurance coverage and general access for cancer patients. National healthcare coverage policy may reduce disparities in cancer care."

"The bottom line from this study," commented William Dale, MD, PhD, of the City of Hope, Duarte, California, "is that the racial disparities between blacks and whites when it comes to speed of treatment basically goes away when you have Medicaid compared to when you don't have Medicaid. The access to timely treatment improves for everyone. For whites it went up a little and for blacks it went up a lot."

But Dale also told 番茄社区 that he was struck that, even in expansion states, only about half the people with metastatic cancer received timely treatment.

Two other studies highlighted at the ASCO press conference also shed light on how having health insurance influences treatment. In one, Anna Jo Smith, MD, of Johns Hopkins University in Baltimore, and a colleague tracked women being treated for ovarian cancer since the ACA went into effect. She and another Hopkins researcher accessed the National Cancer Database and found an increase of 1.7% among women ages 21-64 treated for early-stage ovarian cancer since passage of the law.

"Under the Affordable Care Act, women with ovarian cancer were more likely to be diagnosed at an early stage and receive treatment within 30 days," Smith said at the press conference. "As stage and treatment are major determinants of survival, these gains under the Affordable Care Act may have long-term impacts on women with cancer."

In a third study, Kamal Chamoun, MD, of the University Hospitals Seidman Cancer Center in Cleveland, and colleagues researched outcomes in multiple myeloma cases diagnosed during 2005-2014 by accessing data from the National Cancer Database. That group found that people who had private insurance had a 59% greater probability of survival than people insured through Medicaid, and a 62% better chance of survival compared with people who had no insurance.

The group concluded that "affordability" of oral cancer medications for myeloma may have played a part in these disparities and "merits further investigation."