Is non-expansion a death sentence?

The journey to health care reform has surely been a long one, but for all of the twists and turns, the road to the may culminate in an unanticipated dead-end. Now that we have established health insurance exchanges and expanded Medicaid eligibility, will state governments and ultimately the American people simply let the opportunity to obtain coverage pass them by?

Source: Rod Waddington (Flickr/CC)

Despite the expansion of Medicaid eligibility, many states have declined the invitation to the enrollment party: 23 of 50 states decided not to expand Medicaid, leaving low-income Americans out from the potential benefits of coverage.

Though politically this exclusion has been discussed to death, few media outlets have examined the potential effect on actual mortality for Americans living in states that chose not to participate in Medicaid expansion. According to a study presented at a national health service research meeting, continuous Medicaid enrollment is associated with improved survival among Americans with cancer compared to Americans who remain uninsured.

This has potentially grave consequences for Americans in non-expansion states. Lower income Americans are known to have higher rates of cancer diagnoses, delayed screening for cancer, and more advanced cancers at diagnosis, making effective treatment much more difficult.

This study examined the difference in cancer survival among low-income Californians diagnosed with colon, esophageal, lung, pancreatic, stomach, or ovarian cancer between 2002 and 2008. The researchers assessed if enrollment was associated with cancers that were in earlier stages, making potential treatment more effective. They found that fewer patients who had continuous Medicaid enrollment were diagnosed with cancers that had spread, meaning that their chance for survival would be much higher. Patients who were not enrolled in Medicaid or had interrupted coverage were diagnosed at later stages.

If your state has chosen to withhold Medicaid eligibility from it’s residents, ask why. Are they truly representing their state, or are they continuing to ignore the pleas of vulnerable citizens? There’s no melodrama here, only a decision of life-or-death importance: Are we willing to let Americans die to prove some people’s dissatisfaction with the Affordable Care Act? And, more importantly, is the health of Americans a right or a commodity?

commentary by Farah Kudrath

Abstract

Objective. To examine the effect of Medicaid enrollment on the diagnosis, treatment, and survival of six surgically relevant cancers among poor and underserved Californians. Data Sources. California Cancer Registry (CCR), California’s Patient Discharge Database (PDD), and state Medicaid enrollment files between 2002 and 2008. Study Design. We linked clinical and administrative records to differentiate patients continuously enrolled in Medicaid from those receiving coverage at the time of their cancer diagnosis. We developed multivariate logistic regression models to predict death within 1 year for each cancer after controlling for sociodemographic and clinical variables. Data Collection. All incident cases of six cancers (colon, esophageal, lung, pancreas, stomach, and ovarian) were identified from CCR. CCR records were linked to hospitalizations (PDD) and monthly Medicaid enrollment. Principal Findings. Continuous enrollment in Medicaid for at least 6 months prior to diagnosis improves survival in three surgically relevant cancers. Discontinuous Medicaid patients have higher stage tumors, undergo fewer definitive operations, and are more likely to die even after risk adjustment. Conclusions. Expansion of continuous insurance coverage under the Affordable Care Act is likely to improve both access and clinical outcomes for cancer patients in California. PMID: 25256223

Dawes, AJ et al. Health Serv Res. 2014; 49(6): 1787-811.