ASTRO Annual Meeting

ASTRO Annual Meeting

September 27, 2017
3 min read

Medicaid expansion cuts uninsured rate by half among patients with cancer

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Fumiko Chino

States that enacted Medicaid expansion as part of the Patient Protection and Affordable Care Act showed a reduction in uninsured rates among patients with cancer receiving radiation, according to a study presented at the American Society for Radiation Oncology Annual Meeting.

Medicaid expansion led to a 52% decrease in the number of uninsured patients with cancer receiving radiation therapy. Conversely, that rate dropped only 5% in states that had not fully enacted Medicaid expansion.

“Our study represents a necessary evaluation of a national health care initiative,” Fumiko Chino, MD, radiation oncology resident at Duke University School of Medicine, told HemOnc Today. “The Affordable Care Act has fundamentally changed the insurance landscape in the United States and improved access through insurance coverage to millions of Americans. Patients and families undergoing cancer treatment represent some of our most vulnerable populations. Our study is the first of its kind to show that the ACA improved insurance coverage for this population of patients receiving cancer-directed radiation treatment.

“Given the ongoing debate on health care reform, which has dominated the news cycle over the past 6 months, studies such as ours provide essential information regarding the changes in insurance status seen within the first year of the ACA Medicaid expansion,” Chino added.

Researchers used NCI’s SEER database to analyze data from 197,290 patients (median age, 55 years; 60% women; 78% white) newly diagnosed with cancer between 2011 and 2014 and who received radiation therapy as part of their treatment.

Chino and colleagues compared the number of patients insured at diagnosis before Medicaid expansion (2011 to 2013) and after (2014), as well as insurance rates between states that fully expanded Medicaid in 2014 and those that did not.

Nearly three-quarters (73%) of the patients lived in states with fully expanded Medicaid programs.

The number of uninsured patients with cancer declined in both expanded and nonexpanded states from 2011 to 2014.

The uninsured rate dropped a relative 53% — from 4.3% to 2.1% (P < .0001) — in expansion states. Correspondingly, these states saw Medicaid enrollment rise from 15.2% to 18%.

Medicaid coverage in these states increased regardless of race. Uninsured rates dropped a relative 56% for white patients (4.3% vs. 1.9%) and 50% for black patients (6% vs. 3%; P < .001 for both).

Further, uninsured rates in expansion states decreased by 46% in low poverty areas (3.9% vs. 2.1%) and 60% in high poverty areas (4.5% vs. 1.8%; P < .0001 for both)


In nonexpansion states, the uninsured rate dropped a relative 5% — from 8.4% to 8% — with a corresponding increase in non-Medicaid insurance (75.7% to 77.1%) and decrease in Medicaid enrollment (15.9% to 14.8%; P < .0001).

Only white patients experienced an increase in coverage status in nonexpansion states. Uninsured rates dropped by 9% for white patients (7.8% vs. 7.1%; P < .0001), whereas uninsured rates rose by 7% for black patients (9.9% vs. 10.6%), although this difference did not reach statistical significance.

The poverty level where a patient lived influenced coverage changes in nonexpansion states only. Low poverty areas showed a benefit (relative decrease, 27%; 4.8% vs. 3.5%; P = .04), whereas high poverty areas did not (relative increase, 2%; 10.9% vs. 11.1%).

“Uninsured patients have worse cancer outcomes and are less likely to receive cancer-directed surgery and/or radiation,” Chino said. “Even if they do receive care, the financial burden of treatment can have lasting effects on families. A medical bankruptcy, for example, can affect the socioeconomic status and mobility of generations. Although our study will not change the clinical practice of cancer providers across the United States, it should provide important information regarding the health care debate.”

The study was limited in scope because it assessed only changes in insurance coverage and not how those changes impacted cancer outcomes such as PFS and OS, Chino said. Additional research is needed to better understand specific changes in access, health care delivery and quality of care.

“Our work focuses on a subset of patients, those who were diagnosed with cancer and received radiation treatment,” Chino said. “We know that there are an unfortunate minority of uninsured cancer patients who never even make it to treatment. We should never lose our focus and our goal to provide the highest quality of cancer care to all patients.” – by Chuck Gormley


Chino F, et al. Abstract LBA-15. Presented at: American Society for Radiation Oncology Annual Meeting; Sept. 24-26, 2017; San Diego.

Disclosures: Chino reports no relevant financial disclosures. Please see the full abstract for a list of all other authors’ relevant financial disclosures.