Cancer, race, and the Affordable Care Act

The United States’ system of health care is riddled with well-documented disparities, many of them rooted in race and ethnicity.

But a recent presentation by Amy Davidoff, a senior research scientist at the Yale School of Public Health, showed that expansion of Medicaid under the Affordable Care Act (ACA) virtually eliminated racial disparities in at least one crucial area: access to treatment for advanced forms of cancer. (She presented the research at the annual meeting of the American Society of Clinical Oncology.)

The ACA allowed states to expand Medicaid to a new group of Americans—adults under 65 with family incomes at or below 138 percent of federal poverty guidelines. Older adults in this group were particularly likely to benefit, as they’d been least likely to be eligible for Medicaid prior to the ACA. Because cancer risk increases with age, they were also the most likely to face a new cancer diagnosis.

To find out how expansion affected disparities in care between black cancer patients and white cancer patients, the researchers reviewed 30,386 health records from the firm Flatiron Health. (Identifying data were erased.) The data covered the period from 2011 (pre-ACA) to 2019 and came from 39 states, 26 of which have expanded Medicaid under the ACA.

Before expansion, black adults with advanced or metastatic cancer were 4.8 percentage points less likely than whites to begin treatment within 30 days of diagnosis. But in states that expanded Medicaid, the percentage of black patients who received nonsurgical treatment within a month rose from 43.5 percent to 49.6 percent. For white patients, the figure rose from 48.3 percent to 50.3 percent—leaving the racial gap well under 1.0 percent.

The disappearance of that gap “suggests that state Medicaid expansions have led to improved health equity,” says Davidoff. She cautions that the study doesn’t prove cause and effect, and that more research is needed. But the findings support previous data showing an association between the ACA and better access to care.