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Research Briefs

May 11, 2021

Medicaid Expansion Alone Does Not Resolve Disparities in Cancer Care

While cancer patients have experienced accelerated treatment timelines, receipt of definitive treatment for minorities and minority-serving hospitals in expansion states did not change compared to those in in non-expansion states

In the United States, Black and Latinx individuals have higher cancer mortality rates than patients of other races. Under the Patient Protection and Affordable Care Act (ACA) in 2014, many states expanded Medicaid eligibility, promising significant gains in coverage for racial minorities. But it remains largely unexplored whether Medicaid expansion has been associated with improved care at hospitals that primarily serve minority populations. A new analysis of National Cancer Database (NCDB) records conducted by researchers at Brigham and Women’s Hospital indicates that while individuals experienced accelerated treatment timelines after the ACA, overall, hospitals that primarily serve minorities (MSHs) did not improve average delivery times for cancer treatments. The findings, published in JCO Oncology Practice, point toward the need for additional reforms to support delivery of care in under-funded health systems.

“Providing people with insurance doesn’t necessarily ensure that they will get the care they deserve,” said corresponding author Quoc-Dien Trinh, MD, of the Division of Urologic Surgery. “This project reminds stakeholders and policymakers that there’s downstream work that has to be done beyond expanding coverage, whether in patient navigation or in making sure that people can afford to miss work to receive care when they need it.”

The researchers did find that within states that expanded Medicaid, the proportion of minorities receiving treatment within 30 days increased by over 3 percent when compared to minority patients in non-expansion states. On the hospital level, however, treatment rates did not improve. Previous studies have shown that hospitals with a higher proportion of minority patients do not perform as well as non-minority-serving hospitals across a number of quality metrics. MSHs served a large proportion of under-insured patients prior to Medicaid expansion, and many remain underfunded.

To determine whether timeliness and access to cancer care improved at MSHs between 2015 and 2016, when a larger proportion of hospitals’ patient populations became insured under the ACA, the researchers examined treatment records for breast, colon, lung and prostate cancer using the NCDB, a nationwide oncology registry. They were able to compare definitive treatment and time-to-treatment at MSHs in states that did and did not expand Medicaid.

“It is possible that providing better health insurance coverage for the patient populations of minority-serving hospitals could improve the quality of care at these hospitals,” said the study’s first author, David-Dan Nguyen, MPH, research fellow ’20 at the Brigham’s Center for Surgery and Public Health and the Division of Urologic Surgery and current McGill University medical student. “However, Medicaid expansion under the ACA did not improve receipt of definitive treatment and timeliness of care for cancer patients treated at MSHs. We need to continue improving care at the facility level and continue targeting quality improvement at these hospitals, in addition to providing coverage to cancer patients.”

The researchers emphasize that expanding access to health insurance remains an important public health measure.

“We’re always hoping to see significant changes when an expansive policy like the ACA is implemented, but this is just the first step of many that needs to be taken in order to achieve equitable, high-quality care,” Nguyen said. “Underfunding is an extrinsic, systemic factor that influences the disparities in care that we observe, and to tackle facility-level disparities we need to think about specific initiatives and policy decisions that can directly impact the care at MSHs.”

There was no funding for this study.

Paper cited: Nguyen DD et al., “The Effect of Medicaid Expansion on Receipt of Definitive Treatment and Time to Treatment Initiation by Racial/Ethnic Minorities and at Minority-Serving Hospitals: A patient-level and facility-level analysis of breast, colon, lung and prostate cancer” JCO Oncology Practice  DOI: 10.1200/OP.21.00010