Better cancer survival rates in states with expanded Medicaid


Among U.S. states, there is a variation in eligibility for Medicaid, the national public health insurance program for low-income people (1 in 5 Americans is covered by Medicaid).

Medicaid eligibility is based on income. Each state sets a limit that is a percentage of the federal poverty level (FPL). The percentage varies considerably from state to state. “For example, in Texas, income eligibility was only 27% of the FPL, but in New York, it was 150%,” notes a cancer researcher who has discovered large differences in cancer survival associated with these variations. .

“We found that patients living in states with lower income eligibility limits for Medicaid had worse long-term survival at different stages of cancer,” said lead author Jingxuan Zhao, MPH, scientist associate of the American Cancer Society.

Survival differences were considerable. For example, for patients diagnosed at an early stage Lung cancer, the risk of death from 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 living in states with limited limits higher.

“Policies to increase Medicaid income eligibility limits, such as expanding Medicaid, can help improve survival after being diagnosed with cancer,” conclude Zhao and colleagues.

The new study is scheduled to be presented at the next annual meeting of the American Society of Clinical Oncology (ASCO), but details were soon published and highlighted in a pre-meeting press session.

Commenting on the study, LCO Pearce, MD, president of ASCO, considers it an important summary because Medicaid is the largest source of funding for health care services for people on lower incomes in the United States. “Last fall, we had over 72 million Americans enrolled in Medicaid, which is a very large potential group of patients,” Pearce said. Medscape Medical News.

This study “provides evidence that state expansion of Medicaid income eligibility is associated with better survival,” he said.

“If you’re patient and have very limited coverage or you may not have any, you probably won’t have screening tests, and if you don’t, you won’t go there to be able to pick up these injuries very early,” he commented.

Similarly, for patients who do not have coverage, treatment may not be affordable, “or if you start treatment, you may not be able to have the full complement of treatment because you do not have coverage,” he said.

“I think this summary has significant implications for where we stand in the United States right now in relation to the variability of Medicaid expansion,” he said.

Important coverage, problems remain

Another expert agreed that this is a good study that shows that it would be advantageous for patients to be eligible.

“If they are able to get coverage at the right time, even if they are relatively healthy, they will benefit,” said Emanuela Taioli, MD, PhD, director of the Institute of Translational Epidemiology and professor of science and policy. population health and thoracic surgery at the Icahn School of Medicine in Mount Sinai, New York City. “Then they can get screening, early detection, and even if they are diagnosed with cancer, they can get treatment. So survival will be better if you put all these pieces together.”

Taioli noted that no information is available on whether the cancers were detected by screening or clinically. “My suspicion is that because they had coverage, they were subjected to more screening, because their survival is better, so it can mean that their cancer has been detected at a more curable stage, which happens with screening “.

In addition, the costs of the study treatment were not mentioned. He noted that it is important to know what the related costs are and how they were affected by the costs by the eligibility requirements. “I imagine the costs are lower, because, as we know, palliative care can be very expensive.”

There are other Medicaid-related issues in addition to eligibility criteria, Taioli said Medscape Medical News. One of them is the complexity of the Medicaid system. “It’s very difficult to navigate, so there are probably a lot of eligible people, but you don’t know how to access it,” he said. “They may not even know they are eligible. Therefore, access remains a problem even if they are eligible, and sometimes it is the hospital that does the work when a patient is admitted. But this is not the best way to get insurance coverage. “

Another problem is that many providers do not accept Medicaid, which aggravates the access problem. “It can be difficult for patients to find a doctor even if they are eligible,” he said. “That way, patients can end up with suboptimal care even if they are insured.”

Adrien Bernstein, MD, a member of the Fox Chase Cancer Center, Philadelphia, Pennsylvania, noted that “the social determinants of health are the conditions in which we are born, grow, live, work, and age, and we are responsible for health inequalities.

“Many studies have shown that differences in the clinical outcomes of cancer patients are largely determined by access to care, a key social determinant of health,” he said. He noted that this fact was further underscored in the current study, which included a cohort of nearly 1.5 million American cancer patients.

“They found that survival after 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,” Bernstein said. “This study provides more evidence that greater access to care through insurance coverage is a significant way to improve the survival of cancer patients.”

Complex system for establishing eligibility

The FPL is an economic measure used to determine whether a person’s or family’s income level qualifies them for certain federal benefits and programs. The Department of Health and Human Services updates its poverty guidelines each year and sets the minimum amount of income a family needs for needs such as food, clothing, transportation and shelter.

In 2021, the The FPL is $ 26,500 for a family or a home of four people living in one of the 48 contiguous states or in the District of Columbia (Alaska and Hawaii are considered separately, due to the high cost of living there). The FPL is $ 12,880 for a single person and $ 17,420 for a two-person household.

In the United States, low-income individuals and families rely on Medicaid for their health insurance, but the way eligibility is established is complex.

One of the goals of the Affordable Care Act (ACA) was to provide equity in access to health care and outcomes, expanding Medicaid coverage and providing subsidies for the purchase of private insurance. Through the ACA, Medicaid enrollment increased as a result of people becoming eligible, as well as people who had been eligible but had not previously enrolled.

The decision to expand Medicaid fell into the hands of individual states. By May 2021, 39 states and the District of Columbia had adopted the Medicaid expansion; 12 states had not done so.

A study presented at last year’s ASCO meeting showed that in states that adopted the expansion of Medicaid after the implementation of the ACA, cancer mortality rates decreased compared to states that did not expand. Medicaid. Overall, cancer mortality decreased by 29% in states that expanded Medicaid and by 25% in those that did not.

The latter study further reveals the impact of the expansion of Medicaid, specifically in terms of 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 (ages 18 to 64) who had recently been diagnosed with 17 common cancers between 2010 and 2013. These patients were covered by Medicaid prior to the implementation of the ACA’s Medicaid expansion.

Follow-up was up to eight years; survival time was measured from the time of cancer diagnosis until December 31, 2017.

The states were divided into three categories based on Medicaid income eligibility limits, determined based on the percentage of FPL, as follows:

  • For the states with the lower limits, eligibility was ≤50% of the FPL.

  • For states with medium limits, eligibility ranged from 51% to 137% of FPLs.

  • For the 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 worse among cancer patients 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 observed among patients living in states with the highest eligibility limits.

Zhao, Taioli and Bernstein have not revealed any relevant financial relationship.

American Society of Clinical Oncology (ASCO) 2021: Abstract 6512.

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