Adams et al. Respond

We are most grateful to Barwise for sharing her insights and the additional evidence that she supplies regarding the potential health impact that we can anticipate in nonadopting states. When we consider that many of the cancers that we highlight are amenable to primary prevention using common medical screening procedures (e.g., colonoscopy for colorectal cancer and Papanicolaou test for cervical cancer), it adds weight to our concerns because the mortality-to-incidence ratio (MIR) for these cancers should ultimately trend toward zero.

In 2009, we proposed using the MIR as a way to deepen understanding of cancer disparities in places like South Carolina, where differences in mortality rates across racial groups vary markedly.¹ Subsequently, the MIR was used in Georgia to relate cancer mortality experience to attributes of the health care delivery system.² In 2015, we showed that among the 34 Organization for Economic Co-operation and Development countries (including the United States), attributes of the medical care delivery system, including screening policy, are strongly associated with colorectal cancer MIRs.^3,4 Other recent work also points to the importance of widespread health care access in determining the likelihood of dying given a cancer diagnosis.

Using the MIR, we have demonstrated an impact of the concentration of federally qualified health centers (FQHCs) on decreasing MIR statistics.^5,6 Because FQHCs are the medical home of choice (if not necessity) for diverse and vulnerable populations, we believe that they provide a useful example of the potential of Medicaid expansion. This is especially relevant because most FQHCs do not provide direct patient oncology care, but rather would most likely provide benefit to patients at the two ends of the cancer continuum (i.e., screening to prevent and downstage disease at the time of diagnosis and long-term follow-up care). Thus, the question becomes, if we are able to see a significant difference in smaller cohorts (e.g., the FQHC population) through intervention in screening and follow-up care, what improvements in outcomes could we realize across the entire continuum of cancer care if we expanded health care access to all individuals? In that scenario, we might expect to see a halving of all current MIRs, as we observed for colorectal cancer.³ Our experience over the 45 years of the “War on Cancer” has taught us that the most effective and efficient ways to reduce cancer mortality involve improving and expanding methods of primary prevention and early detection.⁷