ACA Medicaid Expansion Reduces Disparities in Cancer Care

CHICAGO — Previously reported racial disparities in receiving timely cancer treatment between black and white patients almost completely vanished in states where access to Medicaid was expanded under the Affordable Care Act (ACA).

Black patients were able to receive treatment in a more timely manner as a result of being able to receive Medicaid coverage, which in turn provided more equity in care.

These findings (abstract LBA1) were presented here during the plenary session at the 2019 American Society of Clinical Oncology (ASCO) Annual Meeting.

"This study extends prior evidence regarding effects of ACA expansions on insurance coverage and general access for cancer patients," said study 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, New Haven, Connecticut. "National healthcare coverage policy may reduce disparities in cancer care."

In a discussion of the paper, Yousuf Zafar, MD, MHS, associate professor of medicine at Duke University School of Medicine and a member of the Duke Cancer Institute in Durham, North Carolina, commented that this is a "practice changing study" and that it "serves as proof of concept that health policy can impact cancer care quality and reduce racial disparity."

He reiterated that there is a large body of evidence that racial disparities exist in cancer outcomes, and in many cases these are cancers for which diagnostic and treatment modalities exist.

We need to level the playing field. Yousuf Zafar, MD, MHS

"So it's not that we need innovation to close this gap," he said. "We need to level the playing field."

"Cancer injustice is not a science problem, a technology problem, or a genetics problem — it's a policy problem," Zafar emphasized.

In a related study (abstract LBA5563) that was also presented at the ASCO meeting, an analysis found that after the implementation of the ACA, ovarian cancer was diagnosed and treated at an earlier stage among women under the age of 65 years.

In addition, a larger proportion of patients also received treatment within 30 days of diagnosis, thus improving the chances of survival.

"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 of diagnosis," said lead study author Anna Jo Smith, MD, MPH, resident in the Johns Hopkins Department of Gynecology and Obstetrics, Baltimore, Maryland. "As stage and treatment are major determinants of survival, these gains under the ACA may have long-term impacts on women with ovarian cancer."

Disparities Vanish

Racial disparities in cancer outcomes continue to remain a challenge, and some research suggests that these differences may be due more to socioeconomic barriers to quality care rather than race. In prostate cancer, for example, when men were treated within systems with equal access to care or within the standardized treatment approach and follow-up of a cooperative group trial, there was no difference in the prostate cancer specific mortality rates between black and white patients, as reported recently by Medscape Medical News.

One of the goals of the ACA was to provide equity in healthcare access and outcomes by allowing the expansion of Medicaid coverage, along with providing subsidies for purchase of private insurance. Medicaid, which is administered by the states and provides 100% of healthcare coverage for low income persons, had large increases in enrollment that included those who were newly eligible as well as those who had been eligible but had not enrolled previously.

By January 2019, 33 states and Washington, DC, had implemented Medicaid expansion.

Davidoff and colleagues hypothesized that Medicaid expansion would reduce disparities in timely treatment of black patients compared with white patients with advanced cancer, and they looked at data starting 2 years after the Medicaid expansion.

The team used the nationwide the Flatiron Health electronic health record-derived database, and selected patients between the ages of 18 - 64 years with advanced or metastatic cancer (NSCLC, breast, urothelial, gastric, colorectal, renal cell, prostate, and melanoma) who were diagnosed between January 1, 2011, and December 31, 2018.

The primary outcome was timely treatment to systemic cancer treatment that was initiated within 30 days of diagnosis. Patients diagnosed in states after Medicaid expansion were compared with the pre-expansion period or in states not expanding by 2019. The experience of black relative to white patients was also compared.

The final cohort included 34,067 patients, with a median age of 57 years and of whom 12% were black.

Prior to expansion, racial disparities were observed. White patients had a 41.8% predictive margin of timely treatment before Medicaid expansion; afterward, it increased to 43.1%, for a change of 1.8%. Among black patients, the predictive margin for timely treatment was 39.1% prior to expansion, while afterward it increased to 44.3%, for a change of 6.9%.

"The disparities basically disappeared under expansion," said Davidoff.

Overall, black patients were 4.9% less likely to receive timely treatment before Medicaid expansion, but now prior racial disparities were no longer evident between black and white patients. Regardless of race, Medicaid expansion trended toward an increase in timely treatment overall (P = .05) and was associated with a differential benefit for black patients as compared with white ones (6.9% and 1.8%, respectively).

"The study demonstrated that regardless of race, Medicaid expansion had an increase in timely treatment for all patients and this was most notable among African American patients, and the disparity among this group was no longer observed," Cardinale B. Smith, MD, PhD, director of quality for cancer services at The Tisch Cancer Institute, Mount Sinai Health System, New York City, told Medscape Medical News.

In his discussion of the paper, Zafar noted that the study has certain limitations. Since this is not a randomized trial, the findings are associations, and not causations. "We don't know how results may have differed based on unmeasured variables, such as income, patient reported outcomes, patient preferences," he pointed out. "We don't know what happened after treatment initiation — if patients who started treatment earlier actually did better. And we don't know if time to treatment is the best quality metric to assess."

But overall, despite improved access and reduction of disparities as seen in this study, the quality of cancer care has room for improvement. "It’s possible that the path for improvement is paved with real-world evidence which can identify policy solutions to improve care, quality, and outcomes," he concluded.

Benefits in Ovarian Cancer

In the second study, Anna Jo Smith and colleagues conducted a "difference-in-differences analysis" as they compared two groups of ovarian cancer patients: women aged 21 - 64 years pre- and post-2010, and women aged 65 years and older during the same two time periods.

Using data derived from the National Cancer Database, with the 2004 - 2009 surveys showing pre-ACA years and the 2011 - 2014 surveys showing post-ACA data, the authors analyzed data by overall outcomes as well as by insurance type, adjusting for confounders including patient race, living in a rural area, area-level household income and education level, and distance traveled for care.

The cohort included 35,842 ovarian cancer cases pre-ACA and 37,145 post-ACA among women aged 21 - 64 years, and 28,895 and 30,604 cases among those 65 years and older, respectively. The older group served as controls because they had access to Medicare and a much lower risk of being uninsured either pre- or post-ACA.

Researchers' analysis showed that the ACA was associated with increased early stage diagnosis for women aged 21 - 64 years as compared with the control group. There was a relative gain of 1.7% in early stage diagnosis (P-for-trend = .001), as well as a relative improvement of 1.6% in women being treated within 30 days of diagnosis for those age 21 to 64 as compared with women 65 and older (P < .001).

"In our differences to differences model, where we compared the two groups, we could see a trend of about 2% of women receiving timely care in the group of women impacted by the Affordable Care Act," said Smith.

Patients who received public insurance post-ACA saw the greatest benefits. Among publicly insured women, there were relative gains of 2.5% in early stage diagnosis (P = .003) and in receiving treatment within 30 days of diagnosis (P = .006). All the above improvements were seen regardless of race, income, or educational level groups.

Commenting on the study, ASCO Expert Merry Jennifer Markham, MD, FACP, noted that in ovarian cancer, "we know that women diagnosed at later stages have much worse survival than women diagnosed at early stages."

"What's interesting about this study is that it shows that access to healthcare can eliminate disparities in ovarian cancer," Markham said. "And access to healthcare can actually improve long-term outcomes by increasing access to earlier diagnosis and treatment."

Flatiron Health funded the disparities study. Davidoff has disclosed consulting or advisory role with Amgen, consulting or advisory roles (immediate family member) with Celgene and Abbvie; other relationship with PhRMA Foundation; honoraria (immediate family member) with Celgene, Kyowa Hakko Kirin, Jazz Pharmaceuticals, and Tolero Pharmaceuticals; and research funding (institutional) from Boehringer Ingelheim and Celgene. Several coauthors also have disclosed relationships with industry as noted in the abstract. C. Smith has received honoraria from Teva pharmaceuticals. Zafar has disclosed relationships with Shattuck Labs and AIM Specialty Health, Copernicus WCG, Discern Health, Family Reach Foundation, McKesson, RTI Health Solutions, Vivor, and AstraZeneca (institutional).

The ovarian cancer study was funded by a Kelly Society Grant from Johns Hopkins Department of Gynecology and Obstetrics. A.J. Smith and colleagues have disclosed no relevant financial relationships. Markham has disclosed relationships with Aduro Biotech (institutional), Lilly (institutional) and Tesaro (institutional).

2019 American Society of Clinical Oncology (ASCO) Annual Meeting: Abstracts LBA1 and LBA5563. Presented June 2, 2019.

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