By expanding Medicaid coverage for poor and disadvantaged individuals through the Affordable Care Act, survival disparities separating Black and White patients with gastrointestinal (GI) cancer in states adopting this program were significantly reduced, according to a study presented during the 2023 ASCO Annual Meeting. Among states who have not opted to provide Medicaid expansion, adjusted 2-year mortality rate differences among Black and White patients with GI cancer remained the same or even worsened.
"Expanding Medicaid is one attainable and concrete solution that has been found to be associated with improved survival outcomes," said Naveen Manisundaram, MD, a physician in the Department of Neuroscience at Baylor College of Medicine in Houston, who presented the study at ASCO. "Additionally, Medicaid expansion can serve as a solution to reduce survival disparities between Black and White patients."
Julie Gralow, MD, FACP, FASCO, Chief Medical Officer and Vice President of ASCO who moderated the press briefing, said this study demonstrated that Black patients benefited from Medicaid expansion with access to care improved in the form of chemotherapy and surgery.
"Hopefully, with solid data like this, we will be able to provide evidence that Medicaid expansion and the resulting improved access to care can really help overcome the inequities in access," she added.
The Medicaid expansion provision of the Affordable Care Act, passed by Congress in 2010, provided federal funding to participating states to improve health care access for disadvantaged populations by expanding the criteria for Medicaid.
Non-elderly adults with income up to 138 percent of the federal poverty level ($14,580 annually for an individual in 2023) are now eligible for Medicaid, with enhanced federal matching funds (now at 90%), whereas Medicaid eligibility is markedly more restrictive in non-participating states. Some 42 states and the District of Columbia have adopted this provision, mostly after it was first implemented in 2014. That leaves eight other non-expansion states, predominantly in the southeastern part of the country with a higher proportion of Black residents.
Generally, minority residents are less likely to be insured, with rising costs making preventative screening and cancer treatment virtually prohibited for these patients. Given that the proportion of Black patients in non-expansion states is higher than in expansion states, existing racial disparities in access to cancer treatment nationally may actually be magnifying, according to a study published in the September 15, 2022, issue of the journal Cancer (https://doi.org/10.1002/cncr.34346).
Study Details
As outlined during ASCO, this latest study sought to investigate the impact of Medicaid expansion on racial survival disparities between Black and White patients with gastrointestinal malignancies at any stage, including pancreatic, colorectal, and gastric cancers.
A cohort of 86,052 patients was analyzed for this study using the National Cancer Database, including 19,188 patients with pancreatic cancer, 60,404 with colorectal cancer, and 6,460 patients with gastric cancer. A difference-in-difference analysis (DID) was performed to compare adjusted 2-year mortality separating White and Black patients residing in Medicaid expansion states (MES) and non-expansion states (non-MES) before expansion (2009-2013) and after expansion (2014-2019). Differences in receipt of surgery and chemotherapy were also evaluated.
Specifically, the researchers found that 2-year mortality decreased by 11.8 percent among Black patients with pancreatic cancer residing in Medicaid expansion states compared to a decrease of 2.4 percent in non-Medicaid expansion states (DID -9.4%, p<0.001).
For colorectal cancer, 2-year mortality rates for Black patients in expansion states decreased 4.9 percent and 6 percent for White patients compared with a decrease of 2 percent for Black patients and 1.8 percent decrease for White patients in non-expansion states (DID -4.2%, p<0.001 and -2.9%, p=0.047). Among colorectal cancer patients with Stage IV disease, there was a net increase in surgery in the Medicaid expansion states of 13 percent compared with a 5.2 percent increase in surgery in the non-Medicaid expansion states.
Among patients with gastric cancer, Black patients in expansion states experienced a marked reduction in mortality compared with those in non-Medicaid expansion states (DID 3.7%, p=0.28 and DID 2.7%, p=0.20). Rates of surgery, but not chemotherapy, increased among Black patients with Stage IV colorectal cancer in expansion states (DID 5.7%, p=0.03 and 1.0%, p=66, respectively). A greater increase in receipt of chemotherapy was observed among Black patients with Stage IV gastric cancer in expansion states than in non-expansion states (DID 11%, p=0.06).
"Across all three disease sites-pancreatic, colorectal, and gastric cancers-there was an improvement in mortality rates over time in both patients in expansion and non-expansion states," Manisundaram noted. "For both Black and White patients, mortality rates in expansion states were better than mortality rates in non-expansion states.
"For Black patients in particular, improvements in mortality rates were consistently higher in expansion states than in non-expansion states. Improvements in mortality rates for Black patients were even more pronounced in advanced stage disease."
In the future, the researchers said they intend to examine the potential impact of Medicaid expansion on survival and treatment for other cancer types
Warren Froelich is a contributing writer.