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Editor's Comment
Medicaid

Changes in Cancer Staging and Timely Treatment After Medicaid Expansion

  • 1Editor, JAMA Health Forum
  • 2Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor

Before the Affordable Care Act (ACA) was enacted in 2010, adults without health insurance were more likely than those with private insurance to be diagnosed with breast cancer or colorectal cancer at an advanced stage.1,2 Two principal motivations for the ACA were to improve health outcomes for those who would otherwise have no insurance and provide greater financial protection from health care expenses for individuals facing serious illnesses. For adults with cancer, expanded insurance coverage could reduce cost-associated barriers to screening and evaluation of new cancer-associated symptoms and promote more timely access to effective treatments, thereby reducing cancer-associated morbidity and mortality.

In 2006, Massachusetts enacted a broad expansion of health insurance via Medicaid coverage and subsidized private insurance for adults with lower incomes.3 This state health reform law became a forerunner of the ACA. Relative to other nearby states, expanded coverage in Massachusetts was associated with improved access to primary care4; greater use of screening tests for colorectal, breast, and cervical cancer4,5; diagnosis of colorectal cancer (but not breast cancer) at an earlier stage6; and lower mortality rates, particularly for conditions amenable to health care.7

A recent study in JAMA Network Open by Takvorian et al8 assessed whether Medicaid expansion under the ACA has been associated with improvements in stage at diagnosis and time to initial treatment for adults aged 40 to 64 years who were diagnosed with breast, colon, or non–small cell lung cancer. In a difference-in-differences analysis of the National Cancer Database that included more than 1500 US hospitals, diagnoses of stage I cancer increased significantly by 0.8 percentage points and stage IV cancers decreased by 0.5 percentage points in 24 states that expanded Medicaid in 2014, relative to other states that did not. However, initiation of treatment within 30 or 90 days for patients newly diagnosed with cancer did not differ significantly between Medicaid expansion and nonexpansion states.

Studies, such as this one,8 that compare cancer outcomes in Medicaid expansion and nonexpansion states may underestimate the outcomes of Medicaid expansion, particularly if adults with all levels of income are included. First, prior studies showed that the largest improvements in cancer screening after Massachusetts expanded insurance coverage in 2006 were concentrated among those with the lowest incomes,4,5 so these changes may be diluted in studies of the whole population. Second, many adults in nonexpansion states with incomes between 100% and 138% of the federal poverty level, who would have qualified for Medicaid in expansion states, received subsidized private insurance through ACA-authorized Marketplace plans at relatively low cost. Third, under the ACA, adults with insurance in all states benefited from the elimination of cost-sharing for effective preventive services, including screening tests for breast, colon, and lung cancer.

The associations of the ACA and Medicaid expansion with cancer screening, diagnosis, treatment, and outcomes are crucial for patients, health care professionals, and policy makers to understand more fully. With 12 more states opting to expand Medicaid since the initial 24 expansion states studied by Takvorian and colleagues,8 opportunities to assess the role of Medicaid expansion in cancer care remain important and timely.

References
1.
Ayanian  JZ, Kohler  BA, Abe  T, Epstein  AM.  The relation between health insurance coverage and clinical outcomes among women with breast cancer.  N Engl J Med. 1993;329(5):326-331. doi:10.1056/NEJM199307293290507PubMedGoogle ScholarCrossref
2.
Roetzheim  RG, Pal  N, Tennant  C,  et al.  Effects of health insurance and race on early detection of cancer.  J Natl Cancer Inst. 1999;91(16):1409-1415. doi:10.1093/jnci/91.16.1409PubMedGoogle ScholarCrossref
3.
Ayanian  JZ.  The Massachusetts journey to expand health insurance coverage.  J Gen Intern Med. 2012;27(2):139-141. doi:10.1007/s11606-011-1940-1PubMedGoogle ScholarCrossref
4.
Van Der Wees  PJ, Zaslavsky  AM, Ayanian  JZ.  Improvements in health status after Massachusetts health care reform.  Milbank Q. 2013;91(4):663-689. doi:10.1111/1468-0009.12029PubMedGoogle ScholarCrossref
5.
Sabik  LM, Bradley  CJ.  The impact of near-universal insurance coverage on breast and cervical cancer screening: evidence from Massachusetts.  Health Econ. 2016;25(4):391-407. doi:10.1002/hec.3159PubMedGoogle ScholarCrossref
6.
Sabik  LM, Eom  KY, Dahman  B,  et al.  The impact of Massachusetts health reform on colorectal and breast cancer stage at diagnosis.  Med Care. 2020;58(2):183-191. doi:10.1097/MLR.0000000000001241PubMedGoogle ScholarCrossref
7.
Sommers  BD, Long  SK, Baicker  K.  Changes in mortality after Massachusetts health care reform: a quasi-experimental study.  Ann Intern Med. 2014;160(9):585-593. doi:10.7326/M13-2275PubMedGoogle ScholarCrossref
8.
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. 2020;3(2):e1921653. doi:10.1001/jamanetworkopen.2019.21653PubMedGoogle Scholar
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