The Affordable Care Act Erases Racial Disparities in Care for Advanced Cancers

By | June 4, 2019

Studies presented at the 2019 annual meeting of the American Society of Clinical Oncology (ASCO) have revealed a powerful agent that can lead to earlier detection of ovarian cancer, faster treatment for eight kinds of advanced or metastatic cancer and improved outcomes for people with multiple myeloma. It’s not chemotherapy, surgery, radiation or a scientific breakthrough based on genetics or immunology.

It’s something that is already available, at least to many Americans: good health insurance. In three separate studies presented at ASCO, researchers have demonstrated the powerful role that health insurance coverage can play in improving the health of people with cancer.

One of the studies found that states that took advantage of the opportunity to expand Medicaid under the Affordable Care Act (ACA) also accomplished something that has been stubbornly difficult to achieve: all but eliminating racial disparities in cancer treatment.

Erasing Racial Disparities 

“Timely cancer treatment may improve clinical outcomes,” said Amy J. Davidoff, PhD, senior research scientist at Yale School of Public Health, senior author of a new study that looked at access to Medicaid for 2.2 million people in Flatiron Health’s electronic health record database. Of those, about 30,000 had advanced or metastatic cancer: non-small-cell lung cancer (the most common type of lung cancer), breast, urothelial (bladder), gastric/esophageal, colorectal, renal cell (kidney), prostate or melanoma. The study looked at the percentage of people who received treatment within 30 days of diagnosis. Other research has found that prompt treatment is associated with better outcomes.

Such timely care, however, is often less available to people who are Black. Many studies have reported racial disparities in screening, diagnosis and treatment of various cancers, but finding ways to address them has been a stubborn, seemingly intractable problem.

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This study suggests that Medicaid insurance coverage may be an important part of the solution. Under the ACA, some states expanded Medicaid coverage to people who make about a third (138%) more income than the previous cutoff for Medicaid. It was a natural experiment: 26 states with Medicaid expansion were compared with 15 states that didn’t.

In the states where Medicaid expansion wasn’t available, 48.3% of white people got timely treatment, but only 43.5% of Black people did. In the states where Medicaid was expanded, a greater percentage of white people got access too: 50.3%. But there was an even bigger increase in the percentage of Black people who got timely treatment: 49.6%. The small remaining racial discrepancy wasn’t statistically significant. Says Davidoff, “The racial discrepancy was nearly completely eliminated.” In her ASCO presentation, she dedicated the research to “all cancer patients, who deserve timely access to expert cancer care.”

ASCO’s leadership considered the study so significant that it was selected to be presented at a conference-wide plenary. “This is a practice-changing study,” said Yousuf Zafar, MD, associate professor of medicine at Duke Cancer Institute in Durham, North Carolina. “It serves as proof of concept that health policy can impact cancer outcomes and reduce racial disparities.”

Zafar gave an example from his own practice, introducing the case of a patient named Sylvia who has Stage IV pancreatic cancer. He started her on treatment, but after four months, she lost her health insurance and “immediately had thousands of dollars in medical debt.” Her income, at $ 18,000 a year, was too high for her to qualify for Medicaid in North Carolina, which has not expanded access under the ACA. To qualify, her income would have to be around $ 8,000. “She is a Black woman with metastatic pancreatic cancer living in a state that chose not to expand Medicaid availability.”

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Research has found that nationally, Black people get treatment for lung cancer seven days later than white people; for breast cancer, four days later; for pancreatic cancer, three days later.

“Cancer injustice is not a science problem,” concluded Zafar. “It is not a technology or a genetics problem. It is a policy problem.”

Earlier Ovarian Cancer Detection 

In another study, Johns Hopkins University medical resident Anna Jo Smith, MD, MPH, and colleagues found that the ACA has led to more women with ovarian cancer getting diagnosed and treated earlier. Using data from the National Cancer Database, the researchers compared more than 70,000 ovarian cancer cases between 2004 and 2009 (before the ACA went into effect) and between 2011 and 2014 (when the ACA was implemented).

There was a 1.7% relative gain in early-stage (Stage I or II) diagnosis of ovarian cancer and a relative improvement of 1.6% in women being treated within 30 days of diagnosis. Smith noted that while a 1.7% difference in being diagnosed earlier may not sound very large, for the 22,000 women diagnosed with ovarian cancer in the United States annually, according to an ASCO press release, “it means that close to 400 more women could be diagnosed at an early, treatable stage and have a good chance of living a longer life.”

Better Insurance, Better Outcomes for Multiple Myeloma 

The third study looked at multiple myeloma, a blood cancer that can be treated but not cured. Kamal Chamoun, MD, of University Hospitals Seidman Cancer Center in Cleveland, and colleagues analyzed demographic statistics from the National Cancer Database for 117,000 people with multiple myeloma in the United States, where about 32,000 people are diagnosed with the disease each year.

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Treatment of multiple myeloma is expensive and costs have risen rapidly in the last few years. “In my practice, I had a patient whose out-of-pocket expenses were $ 20,000 a month,” said ASCO expert Catherine Diefenbach, MD, of NYU Langone Medical Center. “He couldn’t afford that. We worked with him to get his co-pay down to $ 40 a month. But not all patients have access to such help.”

The challenges are creating real differences in survival, she notes. The study found that over 30 months, people with private insurance had a 59% greater probability of survival compared to those insured through Medicaid. The study also found that people who made $ 46,000 a year or more had a 16% greater likelihood of surviving than those who made less. Where people got treatment mattered too: Those treated at academic institutions had a 49% greater probability of survival.

This study suggests that some cancer treatments are so expensive that even coverage under Medicaid, which restricts access to certain treatments, may not be enough to provide good outcomes. Said Diefenbach, “Where you live and what insurance you have shouldn’t affect survival from multiple myeloma, but unfortunately it does.”

Click here to read the racial disparities abstract.

Click here to read the ovarian cancer abstract.

Click here to read the multiple myeloma abstract.


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