Expanding Medicaid in North Carolina could sharply lessen the burden of colon cancers in the state and save the lives of thousands of Black men as well as improving access to care for men of all races, researchers report in the 27 January issue of PLOS ONE.
Cancers of the colon and rectum kill tens of thousands of people in the US each year and are particularly common among African American men. For every hundred thousand residents of the US in 2016, 37 cases of colorectal cancer were reported, and 14 deaths. For Black men, the numbers were higher: 49 cases per hundred thousand. And the rates of colon and rectal cancers are higher in Appalachia and the South compared to other parts of the country.
North Carolina, a southern state that extends into Appalachia, declined to expand access to Medicaid as part of the Affordable Care Act. That law, also known as Obamacare, not only required states to set up health insurance exchanges but also gave states the opportunity to use federal money to extend Medicaid to anyone with income up to 138% of the federal poverty level. Previously, Medicaid primarily covered poor women and children. Expanded Medicaid also covered men of working age, if their income was below the threshold.
Researchers at UConn Health and University of North Carolina (UNC) saw an opportunity to use North Carolina as a natural experiment to test whether the expansion of Medicaid could have actually reduced illness--and whether it would have saved money for the state in the long term.
"If we had expanded Medicaid in North Carolina, could we have saved lives?" That was the question Wizdom Powell, director of the UConn Health Disparities Institute, wanted to answer. Powell, UNC systems scientist Leah Frerichs, and their colleagues at UNC created a population model that simulated all the African American and white men in North Carolina, based on county by county demographics. Every individual in the model (more than 338,000 Black men and 1,496,000 whites) was assigned a probability of colon cancer screening, based on real world statistics related to income, race and neighborhood data.
They then ran the model under several different scenarios. One, in which North Carolina set up a health insurance exchange but did not expand Medicaid, mimicked what actually happened. And the rates of sickness and death caused by colon cancer in that scenario match what has actually happened in North Carolina in recent years, giving the researchers confidence the model is accurate.
Other scenarios looked at what would have happened if North Carolina had both expanded Medicaid and set up a health insurance exchange.
And we saw that if we had done that, we would have saved hundreds of Black male lives--and increased cancer screening among both Black and white men."
Wizdom Powell, UConn Health Disparities Institute
"It was enlightening to see the impact on disparities," Frerichs says. And she points out how much the state would gain, for little cost. Initially, by expanding Medicaid the state of North Carolina would pay a couple dollars more for every African American man in 2018, but it would save $5.1 million in cumulative cost savings by 2044. And the state would save $9.6 million in cumulative savings for white males.
The researchers are expanding the model to encompass all adults of all races in the state, and are looking at other questions, such as the effects of proposals like Medicare for all.
Powell, W., et al. (2020) The potential impact of the Affordable Care Act and Medicaid expansion on reducing colorectal cancer screening disparities in African American males. PLOS ONE. doi.org/10.1371/journal.pone.0226942.