New research led by American Cancer Society (ACS) researchers finds that after full implementation of the Affordable Care Act (ACA), the percent of uninsured decreased substantially in Medicaid expansion states among the most vulnerable patients: low-income nonelderly adults with newly diagnosed cancer. Meanwhile the number of uninsured remained persistently high in nonexpansion states. The study, appearing in the Journal of Clinical Oncology, also reports a small but statistically significant shift toward earlier diagnosis (stage 1 disease) for some common cancers in patients residing in expansion states. The authors say the findings could inform ongoing health care reform and reinforces the continued need for additional expansion of access to care, especially for low-income populations.

The focus: Cancer diagnosis

The Affordable Care Act (ACA) permitted states to expand Medicaid coverage to a broad group of low-income people. As of Jan. 1, 2014, 24 states and the District of Columbia had opted to expand the coverage. While Medicaid expansion has been associated with declines in the percent of uninsured and with improved access to care in the general population, little is known about how it affected insurance coverage and stage at diagnosis among patients with newly diagnosed cancer.

To explore the issue further, investigators led by Ahmedin Jemal DVM Ph.D. looked at coverage changes using data among more than 1.7 million patients ages 18 to 64 diagnosed with a first primary cancer between 2011 and 2014 in the National Cancer Database (NCDB), a hospital-based cancer registry jointly sponsored by the American College of Surgeons and the American Cancer Society that captures approximately 70 percent of all cancer cases in the United States.

They found between the pre-ACA and post-ACA periods, the percent of uninsured decreased from 9.6 percent to 3.6 percent in low-income patients who resided in Medicaid expansion states, whereas it decreased from 14.7 percent to 13.3 percent in those low-income patients residing in nonexpansion states. The authors note that the difference in percent uninsured between low- and high-income groups narrowed substantially in Medicaid expansion states, whereas it remained persistently high in nonexpansion states.

Earlier diagnoses

The authors also found a significant, albeit small, shift toward diagnosis of stage I disease for colorectal, lung, female breast, and pancreatic cancers and melanoma in patients who resided in Medicaid expansion states. A similar trend was seen for female breast and lung cancers in nonexpansion states. The authors say the changes are not an extension of past trends, and that their study appears to be the first to document changes in insurance coverage and stage among patients with newly diagnosed cancer after the ACA.

“Coverage status at the time of diagnosis is an important determinant of the initial trajectory of cancer care,” write the authors. “The small shift toward early-stage diagnosis for select common cancers, particularly in Medicaid expansion states, adds to the existing evidence on the positive effects of the Affordable Care Act on improving access to and quality of care in low-income population.”

“Cancer patients diagnosed at early stage of the disease are more likely to be treated successfully and have a better chance of cure,” said Dr. Jemal. “As such, these findings reinforce the need for the expansion of Medicaid or the formation of a comparable program to ensure access to care for all low-income people regardless of their residence.”

Article: Changes in Insurance Coverage and Stage at Diagnosis Among Nonelderly Patients With Cancer After the Affordable Care Act, J Clin Oncol DOI: 10.1200/JCO.2017.73.7817