Did Medicaid expansion cut racial disparities in cancer care?

The Affordable Care Act's Medicaid expansion nearly eliminated a key disparity in cancer care access for white and black U.S. patients, according to a new study unveiled Sunday at the American Society of Clinical Oncology's annual meeting.

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Study details

For the study, Yale University researchers compared how frequently whites and blacks in Medicaid expansion and non-expansion states received chemotherapy within a month of their cancer diagnosis before the provision took effect and now. While chemotherapy is not the only source of treatment for cancer patients, the researchers said they felt it was a good gauge for determining whether disparities existed in access to care.

Blythe Adamson, the study’s lead author and a researcher at Flatiron Health, explained, "If you're the same stage of diagnosis, same age, seen in the same practice, at the same time, there should be no reason why a black patient or a white patient should have a different time to treatment."

To gauge those trends, the researchers examined the EHRs of more than 30,000 patients, including 18,678 patients who were treated for cancer in states that had not yet expanded Medicaid and 11,708 patients who were treated in states that did expand Medicaid. The EHRs included data from 2011, before the ACA's Medicaid expansion took effect, to 2019 and were contained in a database managed by the health data company Flatiron Health.

Findings

The researchers found that before the ACA's Medicaid expansion, 48.3% of white patients received chemotherapy within a month of diagnosis, compared with 43.5% of black patients.

However, the researchers found that difference was nearly eliminated in states that expanded Medicaid under the ACA. The data showed white patients in Medicaid expansion states received the treatment within a month of diagnosis 50.3% of the time, while black patients received such care 49.6% of the time—a difference the researchers said was not statistically significant.

Amy Davidoff, a senior author on the paper and a researcher at the Yale School of Public Health, acknowledged that researchers were unable to adjust for individual patients' economic status and could not determine which patients received Medicaid. However, she said the virtual elimination of the racial gap suggests that state Medicaid expansions "led to improved health equity."

Comments

Health policy experts who were not involved in the research said the findings are consistent with previous research that has found associations between the ACA and improved access to health insurance and medical care.

Justin Bekelman, a radiation oncologist and health policy professor at the University of Pennsylvania, said, "What's new here are findings that the ACA and Medicaid expansions have had specific impacts on patients with cancer, and that's great." But Bekelman said more research must be done to determine the ACA's effect on survival and quality of life.

Meanwhile, other experts noted that the racial-disparities study suggests a new form of inequity is forming in the United States based on geographic location.

Otis Brawley, a Johns Hopkins oncologist and former chief medical and scientific officer at the American Cancer Society, said, "We are moving from black-white disparities to Massachusetts versus Mississippi disparities" (McGinley, Washington Post, 6/2; Herper, STAT News, 6/2; Owens, "Vitals," Axios, 6/3).

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