Among US states, there is vide variation in eligibility for Medicaid, the national public health insurance program for people with low income (1 in 5 Americans are covered by Medicaid).
Eligibility for Medicaid is based on income. Each state fixes a limit that is a percentage of the federal poverty level (FPL). The percentage varies considerably from one state to another. "For example, in Texas, the income eligibility was only 27% of the FPL, but in New York, it was 150%," notes a cancer researcher who has uncovered big differences in cancer survival associated with these variations.
"We found that patients living in states with lower Medicaid income eligibility limits had worse long-term survival within stage across multiple cancer sites," said lead author Jingxuan Zhao, MPH, an associate scientist at the American Cancer Society.
The differences in survival were considerable. For example, for patients diagnosed with early-stage breast cancer, the risk for death due to any cause was 31% higher in states with low Medicaid income eligibility limits and 17% higher in states with medium limits, compared to similar patients who were living in states that had higher limits.
"Policies to increase Medicaid income eligibility limits, such as Medicaid expansion, may help improve survival following cancer diagnosis," Zhao and colleagues conclude.
The new study is scheduled to be presented at the forthcoming annual meeting of the American Society of Clinical Oncology (ASCO), but details were released early and were highlighted in a premeeting press briefing.
Commenting on the study, Lori Pearce, MD, president of ASCO, feels that this is an important abstract because Medicaid is the largest source of funding for medical services for people with lower incomes in the United States. "As of this past fall, we had more than 72 million Americans who were enrolled in Medicaid, which is a very, very large potential group of patients," Pearce told Medscape Medical News.
This study "provides evidence that state expansion of Medicaid income eligibility is associated with better survival," she said.
"If you're a patient and you have very limited coverage, or you may not have any coverage at all, you're probably not going to have screening tests, and if you don't have screening tests, you're not going to be able to pick up those very early lesions," she commented.
Similarly, for patients who have no coverage, its likely that treatment will be unaffordable, "or if you do start treatment, you may not be able to have the full complement of treatment because you don't have coverage," she said.
"This abstract, I think, has significant implications of where we are in the US right now with regard to variability of Medicaid expansion," she said.
Coverage Important, Issues Remain
Another expert agreed that this is a good study that shows that it would be advantageous for patients to become eligible.
"If they are able to get coverage at the right time, while they are still relatively healthy, then they benefit," said Emanuela Taioli, MD, PhD, director of the Institute for Translational Epidemiology and a professor of population health science and policy and of thoracic surgery at the Icahn School of Medicine at Mount Sinai, in New York City. "Then they can get screening, early detection, and even if they are diagnosed with cancer, they can get treated. So survival is going to be better if you put all of these pieces together."
Taioli noted that no information is available on whether the cancers were detected by screening or clinically. "My suspicion is that since they had coverage, they did undergo more screening, because their survival is better, so it may mean their cancer was detected at a more curable stage, which happens with screening."
In addition, there was no mention of costs of treatment in the study. It is important to know what the related costs are and how costs were affected by the eligibility requirements, she pointed out. "I would imagine that costs are lower, because, as we know, palliative care can be very expensive."
There are other problems regarding Medicaid in addition to eligibility criteria, Taioli told Medscape Medical News. One is the complexity of the Medicaid system. "It is very difficult to navigate, so there probably are a lot of people who are eligible, but they don't know how to access it," she said. "They may not even know they are eligible. So access is still a problem even if they are eligible, and sometimes it is the hospital that will do the work when a patient is admitted. But that's not the optimal way to get insurance coverage."
Another problem is that many providers do not accept Medicaid, which compounds the problem of access. "It may be difficult for patients to find a doctor even if they are eligible," she said. "So patients may end up with suboptimal care even if they are insured."
Adrien Bernstein, MD, fellow at Fox Chase Cancer Center, Philadelphia, Pennsylvania, pointed out that "social determinants of health are the conditions in which we are born, grow, live, work, and age and are responsible for inequities across healthcare.
"Many studies have demonstrated that differences in clinical outcomes for cancer patients are largely shaped by access to care, a key social determinant of health," she said. She noted that that fact was further emphasized in the current study, which included a cohort of nearly 1.5 million Americans cancer patients.
"They found that survival following newly diagnosed cancer was worse in states that restricted income eligibility to less than 50% of the federal poverty line compared to those with more inclusive eligibility limits," said Bernstein. "This study provides further evidence that increased access to care by insurance coverage is a meaningful way to improve survival among cancer patients."
Complex System to Establish Eligibility
The FPL is an economic measure that is used to determine whether the income level of an individual or family qualifies them for certain federal benefits and programs. The Department of Health and Human Services updates its poverty guidelines every year and sets the minimum amount of income that a family needs for necessities such as food, clothing, transportation, and shelter.
In 2021, the FPL is $26,500 for a family or a household of four persons living in one of the 48 contiguous states or the District of Columbia (Alaska and Hawaii are considered separately, owing to the high costs of living there). The FPL is $12,880 for a single person and $17,420 for a two-person household..
In the United States, Individuals and families with low income rely on Medicaid for their health insurance, but the manner in which eligibility is established is complex.
One of the goals of the Affordable Care Act (ACA) was to provide equity in access to healthcare and in outcomes by expanding Medicaid coverage and by providing subsidies for the purchase of private insurance. Through the ACA, enrollment in Medicaid increased as a result of persons becoming newly eligible as well as the enrollment of persons who had been eligible but who had not enrolled previously.
The decision to expand Medicaid was left up to individual states. As of May 2021, 39 states and the District of Columbia had adopted Medicaid expansion; 12 states had not.
A study presented at last year's ASCO meeting showed that in states that adopted Medicaid expansion following the implementation of the ACA, cancer mortality rates decreased in comparison with states that did not expand Medicaid. Overall, cancer mortality declined by 29% in states that expanded Medicaid and by 25% in those that did not.
This latest study further reveals the impact of Medicaid expansion, specifically with respect to long-term survival among newly diagnosed cancer patients.
For their study, Zhao and colleagues used the National Cancer Database to identify 1,426,657 adults (aged 18–64 years) who had been newly diagnosed with 17 common cancers from 2010 to 2013. These patients were covered by Medicaid before the implementation of Medicaid expansion under the ACA.
Follow-up was up to 8 years; survival time was measured from the time of cancer diagnosis to December 31, 2017.
States were divided into three categories on the basis of Medicaid income eligibility limits, as determined on the basis of the percentage of the FPL, as follows:
For states with the lowest limits, eligibility was ≤50% of the FPL.
For states with medium limits, eligibility was 51% to 137% of FPL.
For states with the highest limits, eligibility was ≥138% of the FPL.
Among all patients in the cohort, 22% lived in states with the lowest limits, 43.5% lived in states with medium limits, and 34.5% lived in states with the highest limits.
Survival rates were worst among patients with cancer living in the first category of states ― those states with the lowest eligibility limits ― followed by those living in states with medium limits. The best survival rates were seen among patients who lived in states with the highest eligibility limits.
Zhao, Taioli, and Bernstein have disclosed no relevant financial relationships.
American Society of Clinical Oncology (ASCO) 2021: Abstract 6512.
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Cite this: Better Cancer Survival Rates in States With Expanded Medicaid - Medscape - May 19, 2021.