ACA Medicaid Expansion: Benefit for Women With Gynecologic Cancers

The Affordable Care Act (ACA) Medicaid expansion benefitted women with gynecologic cancers, according to a retrospective cohort analysis presented at the 2018 Society of Gynecologic Oncology Annual Meeting on Women’s Cancer, held March 24–27 in New Orleans, Louisiana.

“Uninsured rates dropped by a greater magnitude in the states that expanded Medicaid,” reported lead author Haley Arden Moss, MD, MBA, of the Duke Cancer Institute, Duke University Medical Center, in Durham, North Carolina. “Patients living in the highest poverty areas had the greatest benefit from Medicaid expansion.”

However, implementation of other ACA provisions in states that did not implement Medicaid expansion tended to benefit whites and upper-income patients, “leaving Blacks and those living in high-poverty areas with continued disparities in coverage,” Dr. Moss noted.

Uninsured patients have poor cancer outcomes and are more likely to be diagnosed with advanced-stage tumors and to suffer financial hardships. They are also less likely to receive guideline-based treatments, Dr. Moss said. Medicaid expansion was a key provision to increase insurance coverage.

Most provisions of the ACA went into effect in January 2014. (In 2012, the United States Supreme Court ruled that federally mandated expansions of state Medicaid programs were unconstitutional.) Only 22 states sought to expand the number of people covered under Medicaid in 2014. The states that did not participate in Medicaid expansion included those with some of the largest African-American populations in the country.

Using data from the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) cancer registries, Dr. Moss and her colleagues sought to assess how the Medicaid expansion affected racial, ethnic, and socioeconomic disparities in insurance status among 52,917 women who were first diagnosed with cervical, uterine, or ovarian cancer between 2011 and 2014. Only patients younger than 65 years of age were included in the analysis because older women are eligible for coverage under Medicare. Data for women with unknown insurance status were excluded from the analysis.

Seventy-nine percent of patients (41,850 women) were diagnosed in Medicaid-expansion states and 21% (11,067) were diagnosed in non-expansion states. Among women with gynecologic cancers in expansion states, 5.6% were uninsured and 22% were covered under Medicaid, compared with 11.5% uninsured and 21% Medicaid-insured in non–Medicaid-expansion states (P < .0001), Dr. Moss reported.

Overall, the number of uninsured dropped by 56% in states that participated in Medicaid expansion and by 14% in those that did not. The benefits of Medicaid expansion were most dramatic among African-American patients, who saw a 65% decline in uninsured status in Medicaid-expansion states vs a 13% relative decrease in non-expansion states. Those benefits were statistically significant for African-American women with ovarian cancer, who saw a 92% relative decrease in uninsured status in Medicaid-expansion states, compared with a 5% increase in the number of uninsured in non-expansion states.

Among women of all races who had been diagnosed with cervical cancer, expansion states saw a 45% decline in the number of uninsured while those in non-expansion states saw an 8% increase in the ranks of the uninsured. Hispanic women saw a 50% decline in expansion states vs a 16% decline in non-expansion states.

Medicaid expansion disproportionately included white women. A larger proportion of patients in non–Medicaid-expansion states were black (24% vs. 7.7% in expansion states) and fewer were white (72.6% vs. 79.9%). Hispanic patients represented 3.5% and 15% of patients from non-expansion vs expansion states, respectively (P < .0001).

Nineteen percent of patients in Medicaid-expansion states and 37% of those in non-expansion states had income levels in the lowest quartile.

The cancer care community needs to consider how cancer registries might be used to monitor the effects of health policy and to inform future policymaking, Dr. Moss concluded. Oncologists should evaluate possible ways to provide optimal care for patients who have remained uninsured despite the ACA, she said.