These findings, which were presented at a plenary session of the 2019 American Society of Clinical Oncology (ASCO) Annual Meeting and featured at an official press conference, demonstrated that the expansion of Medicaid under the Affordable Care Act (ACA) in 2010 nearly erased racial disparities in cancer care. The study was funded by Flatiron Health.
This is the first time in recent memory that one of ASCO’s plenary sessions featured a study that was not related to new drugs or a change in practice for cancer care. The study results underscore the importance of health insurance access in determining how well all patients with cancer are treated.
“If you can’t access care you can’t benefit from care,” said Richard L. Schilsky, MD, FACP, FSCT, FASCO, Senior Vice President and Chief Medical Officer, ASCO, during the press conference. “For all the advances we’ve observed in recent years in cancer treatment, in cancer care broadly speaking, if you don’t have insurance, if you can’t access care, if you can’t get care in a timely fashion, you can’t benefit.”
The researchers examined blinded electronic health records from Flatiron Health on patients diagnosed with cancer treated at 280 community-based cancer clinics or academic medical centers for a total of 800 sites of care. The analysis included 30,386 people aged 18 to 64 years who have been diagnosed with advanced or metastatic solid tumors between January 2011 and January 2018. Cancer types included lung, breast, urothelial, gastroesophageal, colorectal, renal-cell, prostate, and melanoma.
The researchers compared the electronic health records in Flatiron Health’s database of 18,678 patients who were treated for cancer either before 33 states expanded access to Medicaid benefits under the ACA, or in states that chose not to expand Medicaid, with 11,708 patients who were treated in one of the states that did not expand Medicaid.
In patients treated in states without Medicaid or before Medicaid expansion, white patients received systemic therapy within 30 days of their cancer diagnosis 48.3% of the time compared with 43.5% for African American patients, an absolute 4.8-point difference.
In states where Medicaid was expanded under ACA, the 4.8-point difference was almost completely erased, with a 0.8-point difference between timely cancer care for African Americans versus whites. In states with Medicaid expansion, timely treatment was delivered to 50.3% of whites and 49.5% of blacks, a difference of 0.8%.
“This study extends prior evidence regarding the effect of ACA and tells us that national healthcare coverage policies may reduce disparities. Electronic health records can be a valuable resource for research on treatment patterns, disparities, and interventions,” said senior investigator Amy Davidoff, PhD, MS, Senior Research Scientist, Public Health (Health Policy), Yale School of Public Health, New Haven, CT.
“This work is to be commended. This is some of the best evidence we have to date that policies can impact outcome, particularly timely treatment. Everyone benefits and has some level of improvement. People falling behind before had access to care and disparity disappeared after Medicaid expansion. It is very impressive to see a notable change that was statistically significant. I love when we have evidence like this to inform policy,” commented William Dale, MD, PhD, Arthur M. Coppola Family Chair, Supportive Care Medicine, City of Hope, Duarte, CA.
Effect of Insurance on Ovarian Cancer Diagnosis
A separate study also presented at ASCO and featured at the press conference showed that the ACA led to a substantial increase in the diagnosis of early-stage ovarian cancer (stage I and stage II) in women aged <65 years compared with older women.
Over time, younger women had a 1.7% gain in early-stage diagnosis (stage I or II) compared with older women. A 1.6% improvement was found for younger women being treated within 30 days of diagnosis compared with women aged ≥65 years. Women who were publicly insured had the greatest magnitude of benefit after the ACA was adopted, with gains of 2.5% in early-stage diagnosis and timely treatment compared with women aged ≥65 years. Although these percentages appear small, they affect a large number of patients.
“More than 22,000 women will be diagnosed with ovarian cancer this year and half will be dead in 5 years. We have no screening methods for detection, and by the time patients are symptomatic, the disease is diagnosed at an advanced stage,” explained lead investigator Anna Jo Smith, MD, MPH, MSc, PGY3 Resident, Gynecology & Obstetrics, Johns Hopkins Medicine, Baltimore, MD. “We were interested in determining what the impact of ACA was on earlier stage at diagnosis and treatment of ovarian cancer, since ACA improves access to care and primary care.”
The study was based on women included in the National Cancer Institute database who were diagnosed and treated for ovarian cancer between 2004 and 2009 (pre-ACA; N = 35,842) and between 2011 and 2014 (post-ACA; N = 37,145). Stage at diagnosis and time to treatment were assessed for women aged 21 to 64 years and compared with a group of women aged ≥65 years (controls, because they had access to Medicare and were more likely to be insured pre- and post-ACA).
“The implications of our study are that under the ACA, women with ovarian cancer are more likely to be diagnosed and receive early treatment. These gains may have a long-term impact on survival, health, and well-being for women diagnosed with ovarian cancer,” Dr Smith said.
Speaking at the press conference, ASCO expert Merry Jennifer Markham, MD, Associate Director, Medical Affairs, University of Florida Health Cancer Center, and Program Leader, Multidisciplinary Gynecologic Oncology Program, University of Florida Health, Gainesville, said, “This study shows that access to health care can eliminate disparities and increase access to earlier diagnosis and earlier treatment and ultimately improve long-term outcomes for patients with ovarian cancer.”