Pitt researchers find Affordable Care Act's Medicaid expansions led to earlier detection of cancer

Preventive health care options ushered in by the Affordable Care Act helped doctors detect cancer in more patients earlier and may have reduced the number of late-stage cancer diagnoses around the country, University of Pittsburgh researchers found in a study released Thursday.

“The thing that is sort of potentially groundbreaking with the study is the finding that … we might be seeing the tip of the iceberg here where we’re stopping late-stage diagnoses by catching cancers early,” said Coleman Drake, senior author on the study and assistant professor in Pitt Public Health’s Department of Health Policy and Management.

The peer-reviewed paper published in the American Journal of Preventive Medicine cites some data limitations and the need for further research once more data becomes available regarding the ACA-driven expansions of Medicaid, which enabled millions more Americans to enroll in Medicaid insurance programs.

But the Pitt study points to a bottom line that demonstrates a positive link between Medicaid expansions and cancer detection: Within a year of expansion, states detected 9.4% more early cases of cancer in adults under 64, and within three years, those states saw their cases of late-stage cancer diagnoses slightly drop (5.7%). States that did not enact expansions lagged behind; they did not show significant changes from 2010-13 cancer case and deaths pre-expansion data.

Prostate, breast and colorectal cancers were the top three types detected early at higher rates, though more cancers were detected sooner across the board, the study found.

It’s not that actual rates of cancer or overall cases went up over the same time periods, but that “because more people were insured, these people were able to access care for the first time and they went to a PCP (primary care provider) and then got diagnosed and treatment for cancer,” said the study’s lead author, Lauren Lin, a third-year medical student at Pitt’s School of Medicine.

Total cancer cases did not budge significantly over the periods analyzed, which the study’s authors say makes the reduction in late-stage cancer cases make sense: “Because more people were being diagnosed in 2014, it’s reasonable to hypothesize that maybe those people who were caught earlier then did not develop late-stage cancers.”

Researchers say the study provides more data-grounded evidence to support the positive impacts the Affordable Care Act had on insurance enrollment and increased access to care by previously uninsured Americans. It comes as the Supreme Court mulls the Trump administration’s attempt to repeal the comprehensive law often referred to as “Obamacare.”

Some Republicans in Congress who support the lawsuit pledge to retain popular provisions of the law enacted in 2010 under the Obama administration — but many Democrats and health are advocates warn there is no sufficient replacement plan in place should the lawsuit prevail.

Building on Medicaid expansion research

Thirty-nine states now participate in the ACA’s Medicaid expansion component, which helps provide coverage to more than 725,000 Pennsylvanians. Enrollment has been on the rise as the pandemic and related economic shutdowns and layoffs have left more people without health insurance.

“At a time when 28 million Americans remain uninsured, this study provides evidence that expanding insurance coverage is a potential avenue to improve cancer outcomes,” concludes the new study by researchers at Pitt’s Graduate School of Public Health.

Drake said his research team’s findings add to a growing body of studies demonstrating positive effects of the ACA’s Medicaid expansion component on health outcomes. A study of 2017 data that found Medicaid expansions correlated with lower mortality rates for the near-elderly, “with effects largely driven by decreases in cancer deaths.”

Among other data points that prior studies have highlighted: Medicaid expansions correlating with reduced mortality relates related to cardiovascular health conditions, opioids, patients with end-stage renal disease and “a blanket reduction for all non-elderly adults.”

Increased access to preventive care was a big piece of the ACA, through increased insurance coverage options, subsidies and mandates that all insurers and providers offer basic care such as early cancer screenings and free check-ups by primary care providers.

“It’s really about getting people into the normal health care system rather than presenting at the ED (emergency department) or some other environment when things go wrong,” Drake said. “It allows people to access preventive health care.”

How the Pitt study worked

The Pitt study’s researchers began working on the study more than a year ago. They did the bulk of their data analysis in summer and fall 2019 before submitting the study for publication and the peer review process near the end of last year.

The study aimed to build on the work of colleagues who did similar research based on earlier figures, Drake said.

“Given that we had a few more years of data, we said, ‘Let’s see whether those trends have persisted over time,’ ” Drake said.

Co-author Lindsay Sabik said that though the initial ACA was passed a decade ago, “the key provisions weren’t implemented until 2014,” including Medicaid expansions.

“Because we often don’t see the effects immediately, it’s important for us to keep studying the long-term consequences of health care reform,” said Sabik, associate professor of health policy and management at Pitt Public Health and member of the UPMC Hillman Cancer Center.

Using national cancer registry surveillance and epidemiological data, the study analyzed the impact of the Medicaid expansion on “non-elderly adults” between the ages 18 and 64 in 16 states, some of which implemented the expansion between 2014-16 and others that did not.

Pennsylvania was not included because its data was not available. Coleman said he would expect Pennsylvania’s results to be in line with states such as Michigan, Kentucky, New Jersey and Iowa, which began Medicaid expansions shortly before or after Pennsylvania did so in 2015 under Democrat Gov. Tom Wolf, after Republican Gov. Tom Corbett resisted doing so.

States analyzed saw a 9.14% statistically significant increase in diagnoses of early-stage cancer cases within a year of enacting Medicaid expansions — or about 21.3 cases per population of 100,000, researchers said. The uptick dissipated in subsequent years, “suggesting a response to pent-up patient demand for screening and diagnostic services immediately after expansion.”

“We found that there was an increase in early-stage cancer diagnoses right after Medicaid expansions went into effect in 2014,” Lin said.

The study’s second — and less statistically significant — finding pointed to a 5.7% drop in late-stage cancer diagnoses three years after Medicaid expansions began in 2014, amounting to about 8.7 cases per population of 100,000.

With so much political rhetoric swirling regarding the ACA and the Trump lawsuit’s legal impacts, the health care law as a whole “is being challenged right now and I think it’s become very political,” Lin said.

“But the research has shown that it does have positive impacts on the people who end up being insured under the act,” Lin said.

“We learn a lot in medical school about the importance of preventive medicine, even though sometimes it’s not a priority. In this case, it’s really exciting to see that this high-level system, policy-level change can actually give people the access to care and to get the preventive medicine that they need,” Lin said. “It’s frustrating that there are still so many barriers.”

Aparna Soni of American University in Washington, D.C. co-authored the paper. The University of Pittsburgh study was supported by National Center for Advancing Translational Sciences, National Cancer Institute Cancer Center Support, the Horowitz Foundation for Social Policy and the Pitt School of Medicine Dean’s Summer Research Program.