Medicaid Expansion and Radiation Therapy

(Inside Science) -- A new study looking at how passage of the 2010 Patient Protection and Affordable Care Act impacted people seeking radiation therapy for cancer shows that the legislation improved insurance coverage rates for patients receiving this form of care in the United States.

Presented in September at the American Society for Radiation Oncology meeting in San Diego, the study found significant differences between the states that expanded Medicaid under the Affordable Care Act and those that did not.

Medicaid is a joint federal and state program that provides health insurance for tens of millions of Americans – including families, pregnant women, people with disabilities, and the poor and the elderly. Eligibility for Medicaid was expanded under the Affordable Care Act, but each state controls its own enrollment, and not every state implemented the expansion. As of November 2017, 32 states and the District of Columbia have adopted Medicaid expansions and 18 states have not, according to the Kaiser Family Foundation.

What the new study found was that while the number of uninsured radiation therapy patients dropped in all states, regardless of whether they expanded Medicaid or not, there were steeper declines in those states that did expand the program (a 50 percent relative decline compared to a 5 percent decline in nonexpanded states).

The study also found increased disparities in coverage in states that did not expand Medicaid. In states that expanded Medicaid, uninsured rates declined evenly across all demographic groups. But in states that did not expand, insurance coverage mainly increased among white patients and in areas of low poverty.

Other studies have similarly linked the expansion of Medicaid to increased insurance coverage, but this was the first study to look specifically at the effect of the Affordable Care Act on radiation therapy for cancer care. It was motivated by previous studies that have shown people who lack health insurance generally have worse outcomes from cancer.

“We really wanted to quantify and qualify the changes in insurance status for patients who are actually receiving treatment for their cancer,” said Fumiko Chino, a radiation oncology resident at Duke University in Durham, North Carolina, who led the study. “What we want for all of our patients is the very best and longest life.”

Cancer’s financial burden on the uninsured

People with cancer who are uninsured have significant barriers to care, Chino said. They’re less likely to receive recommended treatment, may be less able to afford medication or take time away from work for treatment, are more likely to miss appointments and are more likely to have their cancer diagnosed at an advanced stage -- all factors that can negatively affect survival.

“I think what the study shows is that by expanding access to these patients, they may be able to decrease some of the costs that these patients faced in having cancer therapy, thus reducing some of the financial toxicity they may have,” said Aileen Chen, a radiation oncologist at the Dana-Farber Brigham and Women’s Cancer Center in Boston who was not involved in the research.

Financial toxicity is a growing concept in the study of cancer therapy. It treats the direct and indirect costs to the consumer as an aspect of care and looks at how those costs may influence outcomes. In some cases, lacking insurance may ultimately force people with cancer into making a “Sophie’s choice” between refusing lifesaving treatment or taking on crushing debt.

“The terror that some families can face with wondering how they’re going to afford their cancer care is something that is real and significant,” Chino said. “They’re worried about bankrupting their families. They’re worried about becoming homeless.”

Anecdotally, Chino added, she knows of some cases where people are not getting the care that they need because they cannot afford it.

Motivated by such cases, Chino and her colleagues undertook their study by examining 197,290 records of people who were newly diagnosed with cancer between 2011 and 2014 and subsequently received radiation therapy. The records were drawn from the National Cancer Institute’s population-based SEER surveillance registry .

What remains to be seen, said Chen is whether this increased insurance rate improves outcomes from treatment.

One weakness of the study, Chino pointed out, is that it only caught people who actually received treatment. But there is a population of uninsured cancer patients who fall between the cracks and never get treated, she said.

“Those patients are out there and they’re not getting the appropriate care that they need,” said Chino. " I think they ultimately show up in the emergency room with metastatic cancer or they may die at home.”

“And that is a tragedy,” she added.