Medicaid Expansion Associated With Lower Mortality in NSCLC

Medicaid expansion has positive implications in terms of mortality in non–small cell lung cancer (NSCLC), according to a new study,¹ as the 2- and 4-year mortality of NSCLC was improved in states that had expanded access to Medicaid, implying that access to effective care improved outcomes for all patients.

NSCLC is the most common form of lung cancer, which is the leading cause of cancer-related deaths in the US. Detecting NSCLC early is the key to prolonged survival,² but this care and treatment is not always accessible to patients, especially those who lack insurance. The long-term effects of expanding Medicaid have been studied in other forms of cancer, but their specific benefits in NSCLC are unclear. This study aimed to find associations between Medicaid expansion and survival outcomes in patients with NSCLC stages I to IIIA who were younger than 65 years.

The researchers used the Surveillance, Epidemiology, and End Results Research Plus Database to collect data from January 1, 2006, through December 31, 2019. Patients who were older than 65 years or had incomplete data were excluded from the study. Resectable NSCLC was identified by the stage, which left all patients in the database with stage III out of the study.

Primary exposure was the status of Medicaid expansion in the state when the patient was diagnosed. There were 4 periods considered for the study: pre-expansion (2006 to 2010), early expansion (2011 to 2013), expansion (2014 to 2016), and late expansion (2017 to 2019). County rurality, cancer stage, age, sex, race, and ethnicity were covariates, and the primary outcome was all-cause mortality within 2 and 4 years of diagnosis.

There were 53,842 patients included in the analysis, of which 49.8% were women. Most of the participants were aged 60 to 64 years (46.2%) and were non-Hispanic White (73.8%).

The expansion group had a decrease in postexpansion mortality (HR for difference-in-difference [DID] interaction, 0.94; 95% CI, 0.90-0.98). The late expansion group also had a decrease in postexpansion mortality (HR, 0.93; 95% CI, 0.87-0.99). Postmatching DID models showed a significant reduction in mortality in the early expansion group (HR, 0.95; 95% CI, 0.91-0.99).

Early expansion states had no significant survival changes during implementation. The postimplementation period of 2014 to 2019 saw decreased mortality hazards across both 2-year and 4-year mortality (2-year HR, 0.89; 95% CI, 0.85-0.93; 4-year HR, 0.91; 95% CI, 0.91-0.99). This was also mirrored across the 2011 to 2019 time period. No differential survival change was observed in 2014 to 2016 for the expansion group, but a significant mortality decrease was found for 2017 to 2019 (2-year HR, 0.85; 95% CI, 0.77-0.94; 4-year HR, 0.86; 95% CI, 0.80-0.93).

The 2-year mortality decrease was not found in late expansion states between 2017 and 2019 but a 4-year survival increase was seen (HR, 0.92; 95% CI, 0.89-0.94). Mortality could not be tracked for this group due to a lack of data beyond 2021.

Patients had improved mortality if they were younger than 55 years (HR, 0.87; 95% CI, 0.79-0.95); were women (HR, 0.69; 95% CI, 0.65-0.71); were non-Hispanic Asian, Native Hawaiian, or other Pacific Islander (HR, 0.49; 95% CI, 0.32-0.77); or were married or in a domestic partnership (HR, 0.76; 95% CI, 0.71-0.80). Participants had higher mortality if they lived in rural (HR, 1.23; 95% CI, 1.08-1.39) or smaller metropolitan areas (HR, 1.21; 95% CI, 1.04-1.41). County rurality, sex, and racial subgroup did not have any relative benefit. Early-stage diagnosis also was not associated with Medicaid expansion.

There were some limitations to this study. Causality could not be inferred due to the retrospective nature of the analysis, and confounding factors could not be accounted for. There also may have been unmeasured state differences that could act as confounders. The cohort also included those with private insurance. Those younger than 65 years who receive Medicare due to disability were included and could have introduced bias. The analysis did not evaluate if diagnoses shifted from stage IV to earlier stages, as the investigation focused solely on stages I to IIIA. Follow-up was also limited to 4 years, which could have missed longer-term analysis.

“In this cohort study, Medicaid expansion was associated with decreased 2- and 4-year mortality in patients with resectable NSCLC, with delayed but sustained decreases emerging over time,” the researchers concluded. “As debates over Medicaid continue, these findings suggest that long-term survival improvements may be achievable through early and comprehensive health policy implementation.”

References

1. Gawdi R, Islam S, Sha C, et al. Statewide Medicaid expansion and survival in resectable non-small cell lung cancer. JAMA Netw Open. 2025;8(12):e254996. doi:10.1001/jamanetworkopen.2025.45996

2. Non-small cell lung cancer. Cleveland Clinic. Updated January 16, 2025. Accessed December 2, 2025. https://my.clevelandclinic.org/health/diseases/6203-non-small-cell-lung-cancer