1. Samson, Kurt

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SAN DIEGO-Expanded Medicaid coverage under the Affordable Care Act (ACA) resulted in a 50 percent increase in radiotherapy being administered to previously uninsured cancer patients, a review of data on almost 200,000 cancer patients has found.


The ACA also decreased socioeconomic and racial disparities in radiation treatment, according to the study, presented in September at the American Society for Radiation Oncology's Annual Meeting (Abstract LBA-15).


Black patients and those living in the highest poverty areas saw the greatest benefit, said lead author Fumiko Chino, MD, Radiation Oncology Resident at the Duke University School of Medicine in Durham, N.C. She discussed the findings at a press briefing.


"We conducted a study looking at insurance patterns before and after Medicaid expansion and found that uninsurance rates dropped significantly following expansion. The program appears to have improved access and decreased health care disparities in cancer patients receiving radiation therapy, with the greatest benefits seen among vulnerable individuals living in the highest poverty areas."

Fumiko Chino, MD. Fu... - Click to enlarge in new windowFumiko Chino, MD. Fumiko Chino, MD

While Medicaid expansion was effective at decreasing disparities and improving access, disparities still exist, she said.


"In states without Medicaid expansion, the rates of uninsured patients went down, but those who benefited were white patients living in higher-income areas, for who it might have been possible to purchase plans through the health care exchange."


Although coverage improved for many patients in expanded Medicaid states, socioeconomic and racial disparities remained higher in low-income parts of other states, the researchers discovered. There were no improvements in uninsured rates for black patients and residents of high-poverty areas in states without Medicaid expansion. In fact, patients in these groups appeared to be losing insurance coverage, although this finding was not statistically significant.


The findings were from an analysis of data in the NCI's Surveillance, Epidemiology and End Results (SEER) database. The study included data on more than 197,290 patients who were newly diagnosed with cancer and received radiotherapy between 2011 and 2014. The patients were all between the ages of 18 and 64 years of age and received radiation therapy.


"Uninsured cancer patients are more likely to go without needed care and treatment, such as radiation therapy or surgery to remove tumors," Chino noted.


Methods, Results

Chino and her associates compared insurance rates between patients in states that fully expanded Medicaid programs under the ACA with those in states that did not. Almost three out of four patients lived in states with fully expanded Medicaid programs.


In both expanded and non-expanded states, the number of uninsured cancer patients fell, but expansion states experienced a steeper decline, they found.


In expanded states, the uninsured rate declined a relative 52 percent, from 4.4 percent to 2.1 percent, while Medicaid enrollment rose from 15.2 percent to 18.0 percent. In non-expansion states, the uninsured rate dropped a relative 5 percent (8.4% to 8.0%), with an increase in non-Medicaid insurance (75.7% to 77.1%) and decrease in Medicaid enrollment (15.9% to 14.9%).


Race was associated with coverage changes in non-expansion states only. In expansion states, coverage increased regardless of race; uninsured rates dropped by a relative 56 percent for white patients, from 4.3 percent to 1.9 percent, and 50 percent for black patients, from 6.0 percent to 3.0 percent. In non-expansion states, only white patients experienced an increase in coverage status.


Uninsured rates dropped by 9 percent for white patients in non-expansion states, from 7.8 percent to 7.1 percent while uninsured rates rose by 7 percent for black patients, from 9.9 percent to 10.6 percent, although the difference for black patients was not statistically significant.


Poverty level similarly influenced coverage changes in non-expansion states only. Uninsured rates in expansion states decreased by 46 percent for patients who lived in low-poverty areas, from 3.9 percent to 1.8 percent versus 60 percent for those who lived in high-poverty areas (4.5% to 1.8%).


In non-expansion states, conversely, only patients in less-impoverished areas experienced an increase in coverage, as the uninsured rate dropped by 27 percent in low-poverty areas (4.8% to 3.5%) but rose by a relative 2 percent in high-poverty areas (10.9% to 11.1%, p = 0.17).


"This study is part of a developing body of research to quantify health care delivery changes under the ACA," Chino said. "We now are assessing if these insurance changes translate to differences in patient survival."



Aileen B. Chen, MD, Assistant Professor of Radiation Oncology at Harvard Medical School and Senior Physician at Dana-Farber Cancer Institute, Boston, told Oncology Times that it will be interesting to see if Medicaid expansion also led to improvements in cancer outcomes. Asked if any other factors aside from Medicaid might have influenced the results, she said that, while it is unlikely, it is possible that changes in the economy might have played a role.


"Higher employment rates in expansion states or changes in radiation therapy provider behavior-providers less willing to accept uninsured patients in expansion states-might partially explain the findings," she noted.

Aileen B. Chen, MD. ... - Click to enlarge in new windowAileen B. Chen, MD. Aileen B. Chen, MD

"Other studies have found that expansion of Medicaid programs can affect insurance rates among patients and narrow disparities in care. But this study is novel in that it focuses on patients receiving radiation therapy for cancer and also that it found that Medicaid expansion decreased racial and economic disparities in insurance rates for patients receiving radiation therapy. This is reassuring since it shows that an expansion in Medicaid was able to help those who are most socioeconomically disadvantaged."


Kurt Samson is a contributing writer.