The recent article by Choi et al.1 highlights the concerns with the nonadoption of the Affordable Care Act (ACA) and expansion of Medicaid in 23 states, and the role this may play in increasing disparities in detection and treatment of cancer. I applaud the authors for calling attention to the coverage gaps that exist for low-income groups in these states.
A large body of evidence supports the concept that increasing insurance coverage can help reduce disparities and equalize access to the health care system.2 Researchers have documented that racial disparities are far less intense in countries such as Canada that have universal health coverage.3 In addition, it has been noted that state Medicaid expansions to cover low-income adults were significantly associated with reduced mortality as well as improved coverage, access to care, and self-reported health.4 Not only are the health risks to the underserved an ethical issue worthy of attention, but future costs (mortality and morbidity) for those with late-stage disease should be part of the discussion.5
As the authors note, the time lag between lack of screening and mortality-to-incidence ratio means the full implications of not expanding Medicaid will be more apparent in five to 10 years, assuming there are no other major considerations that might confound the data. It would be interesting to repeat this study in the future to assess the impact these policy decisions are having on marginalized populations. We should be mindful of the fact that despite widening gaps in the nonadoption states, more people in total will have access to screening and treatment of cancer, and we would hope that the mortality-to-incidence ratio overall will improve in line with this. We would anticipate a reduction in disparities in states that are adopting the ACA and expanding Medicaid.
The ACA was enacted to try to improve access to quality health care and in this way reduce health care disparities. The refusal of some states to adopt the ACA and expand Medicaid will likely mean disparities continue to be seen not only in the area of cancer diagnosis, treatment, and survival, but in all health care domains.
REFERENCES
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