TOPLINE:

In patients with resectable non-small cell lung cancer (NSCLC), Medicaid expansion under the 2014 Affordable Care Act (ACA) was associated with improved 2- and 4-year survival.

METHODOLOGY:

• Medicaid expansion under the ACA broadened eligibility for government-funded health coverage but was adopted variably across US states. Resectable NSCLC requires timely multimodal therapy, but low-income and underinsured patients often face delays. Although prior studies have linked Medicaid expansion to earlier cancer diagnosis and improved survival, its long-term effects on patients with resectable NSCLC remain unclear.
• Researchers analyzed data on 53,842 patients aged 20-64 years with stage I-IIIA NSCLC, collected between January 2006 and December 2019 by the Surveillance, Epidemiology, and End Results (SEER) registry. They focused on the Medicaid expansion status of patients’ state of residence at diagnosis.
• The primary outcome was 2-year and 4-year all-cause mortality. Cox proportional hazards regression models within a difference-in-differences framework were used to estimate adjusted hazard ratios (HRs) for death.
• Propensity score matching was performed using variables including age, sex, race and ethnicity, county-level income, and stage at diagnosis to ensure balanced comparison groups. Patients were grouped as residing in states with Medicaid non-expansion (n = 9896), early expansion (beginning in 2011, n = 28,825), 2014 expansion (n = 10,442), and late expansion (after 2014, n = 4679).

TAKEAWAY:

• In propensity score-matched analyses, patients in early expansion states showed slightly lower 2-year mortality than those in non-expansion states (HR, 0.95; P = .02). A similar pattern was seen in the 2014 expansion states (HR, 0.91; P < .001). No significant difference in 2-year mortality was observed between late and non-expansion states (HR, 0.95; P = .15).
• Era-stratified analyses showed mortality reductions in Medicaid expansion states over time. Overall, survival benefits were not seen in the first 3 years of implementation but became evident thereafter: In the early expansion states, 2-year mortality declined in 2014-2019 (HR, 0.89; P < .001), as did 4-year mortality (HR, 0.91; P < .001). Similarly, the 2014 expansion states observed a significant decrease in mortality in 2017-2019 (2-year HR, 0.85; P = .001 and 4‑year HR, 0.86; P < .001). In late expansion states, 4-year mortality declined in 2017-2019 (HR, 0.92; P < .001).
• No significant changes were observed in the proportion of early-stage diagnoses post-expansion (interaction odds ratio, 1.07; P = .18), indicating that benefits may have been mediated through improved NSCLC care rather than earlier detection.
• Overall, residence in rural and smaller metropolitan counties was associated with higher mortality (HR, 1.21-1.23). And the benefits linked to Medicaid expansion did not extend to residents in states’ poorest counties — suggesting, the authors of the study wrote, that broader eligibility does not sufficiently address structural disadvantages faced by underserved populations.

IN PRACTICE:

“Medicaid expansion was associated with decreased 2- and 4-year mortality in patients with resectable NSCLC, with delayed but sustained decreases emerging over time,” the authors of the study wrote. “While causality cannot be inferred, these findings highlight the role of health policy in supporting access to complex cancer care.”

SOURCE:

The study, led by Rohin Gawdi, MD, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York, was published online in JAMA Network Open.

LIMITATIONS:

The retrospective nature of this cohort study prevented establishment of causality. The SEER database lacked granular patient-level data such as smoking history, comorbidities, and insurance status, potentially leaving residual confounding. The inclusion of patients with consistent private insurance coverage who were not directly affected by Medicaid policy likely biased estimates toward the null, suggesting that the true association between Medicaid expansion and improved survival may have been stronger among Medicaid enrollees.

DISCLOSURES:

The authors of the study did not declare any funding information. No relevant conflicts of interest were reported by the authors of the study.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.