Changes in cancer mortality rates after the adoption of the Affordable Care Act.

Abstract

2003 Background: The Affordable Care Act (ACA) was designed to improve health status in the US primarily through improving access to health insurance. As adoption of Medicaid expansion varied at the state level, this study aims to compare cancer mortality rates over time between states who did (EXP) and did not adopt (NonEXP) Medicaid expansion. Methods: Age-adjusted mortality rates per 100,000 were gathered from the National Center for Health Statistics from 1999-2017 to establish trends. Only deaths due to cancer in patients less than 65 were included. Absolute change in cancer mortality was calculated from 2011-2013 and then from 2015-2017 with 2014 as washout year. Changes within subpopulations (gender, race, ethnicity) were also assessed. Mortality changes between EXP and NonEXP groups were via “difference in differences” analysis. Results: Overall age-adjusted cancer mortality in the US fell from 1999-2017 from 66.9 to 48.8 per 100,000. EXP states had higher population (157 vs 118 million) with less black/African Americans (19.2 vs 21.8 million) and more Hispanics (33.0 vs 21.7 million) than NonEXP states (all examples from 2017). The overall age-adjusted cancer mortality was consistently worse in NonEXP states, cancer mortality fell from 64.7 to 46.0 per 100,000 in EXP states and from 69.0 to 51.9 per 100,000 in NonEXP states from 1999-2017 (both trends p < 0.001, comparison p < 0.001). Comparing the mortality changes in the peri-ACA years (2011-2013 vs 2015-2017) between the 2 cohorts, the difference in differences between EXP and NonEXP states was -1.1 and -0.6 per 100,000 respectively (p = 0.006 EXP, p = 0.14 NonEXP). The estimated overall cancer mortality benefit gained in EXP states after Medicaid expansion (∆∆∆) is -0.5 per 100,000 (p = NS). In EXP states, this translates to an estimated 785 less cancer deaths in 2017. Age-adjusted cancer mortality per 100,000 was worse in NonEXP states for black patients (58.5 EXP vs 63.4 NonEXP in 2017) however there was no differential mortality benefit after ACA expansion when comparing between the peri-ACA years. Of the subpopulations assessed, Hispanics in EXP states had the highest differential cancer mortality benefit at -2.1 per 100,000 (p = 0.07). Conclusions: This is the first study to show a directly measured cancer survival benefit from the ACA on a national scale using a comprehensive database. Hispanic populations appear to have the highest differential cancer mortality benefit after Medicaid expansion. Further study is needed to elucidate why other populations like black patients did not appear to reap the same mortality decrease.