{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,22]],"date-time":"2026-09-22T15:35:17Z","timestamp":1790091317333,"version":"4.0.1"},"reference-count":44,"publisher":"Public Library of Science (PLoS)","issue":"4","license":[{"start":{"date-parts":[[2026,4,9]],"date-time":"2026-04-09T00:00:00Z","timestamp":1775692800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100006545","name":"National Institute on Minority Health and Health Disparities","doi-asserted-by":"publisher","award":["2U54MD007597"],"award-info":[{"award-number":["2U54MD007597"]}],"id":[{"id":"10.13039\/100006545","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Medicaid expansion under the Affordable Care Act (ACA) sought to improve access to timely cancer diagnosis and treatment among low\u2011income populations. Lung cancer remains the leading cause of cancer-related mortality in the United States, and disparities in outcomes may be sensitive to shifts in insurance coverage. This study evaluates the association between Medicaid expansion and both cancer-specific mortality and overall mortality among adults with lung cancer in California (expansion state) compared with Texas (non-expansion state).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We conducted a retrospective cohort study using SEER registry data (2007\u20132021) including adults aged 18\u201364 years diagnosed with lung cancer. The study periods were categorized as pre-ACA (2007\u20132013), washout year (2014), and post-ACA (2015\u20132021). Difference\u2011in\u2011differences (DiD) Cox proportional hazards models estimated the change in the hazard of cancer\u2011specific and overall mortality in California relative to Texas after Medicaid expansion, adjusting for age, sex, race\/ethnicity, stage, county\u2011level income, and treatment. Subgroup analyses evaluated heterogeneity by race\/ethnicity, disease stage, income, and treatment modality.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Among 119,937 individuals with lung cancer, 52.1% resided in California and 47.8% in Texas; sample distribution remained similar across pre\u2011 and post\u2011ACA periods. Medicaid expansion was associated with an 11.9% reduction in the hazard of cancer\u2011specific mortality (DiD HR 0.88; 95% CI, 0.85\u20130.91) and an 11.4% reduction in the hazard of overall mortality (DiD HR 0.89; 95% CI, 0.86\u20130.91). Mortality reductions varied across subgroups. Significant improvements were observed among White, Hispanic, and Asian\/Pacific Islander patients, while no statistically significant change occurred among Black patients. Greater reductions in the hazard of death were seen among patients with distant-stage disease and those residing in higher\u2011income areas (\u2265$65,000). Treatment-stratified models showed decreases in mortality among individuals receiving surgery (10.2% reduction) and chemotherapy (8.4% reduction).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec004\">\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Medicaid expansion was associated with meaningful reductions in lung cancer mortality in California relative to Texas, with benefits concentrated among several racial and clinical subgroups. Persistent null effects among Black patients highlight inequities that insurance expansion alone does not eliminate.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0332292","type":"journal-article","created":{"date-parts":[[2026,4,9]],"date-time":"2026-04-09T17:39:01Z","timestamp":1775756341000},"page":"e0332292","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":2,"title":["Association of medicaid expansion with lung cancer\u2013specific and overall mortality: A difference-in-differences analysis"],"prefix":"10.1371","volume":"21","author":[{"given":"Oluwasegun","family":"Akinyemi","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mojisola","family":"Fasokun","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-7521-2224","authenticated-orcid":true,"given":"Akachukwu","family":"Eze","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nkemdirim","family":"Ugochukwu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sumaiyya","family":"Arshad","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Orimisan","family":"Belie","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kakra","family":"Hughes","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Edward","family":"Cornwell III","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gal","family":"Levy","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,4,9]]},"reference":[{"key":"pone.0332292.ref001","unstructured":"American Cancer Society. Special Section: Lung Cancer. 2023. https:\/\/www.cancer.org\/content\/dam\/cancer-org\/research\/cancer-facts-and-statistics\/annual-cancer-facts-and-figures\/2023\/2023-cff-special-section-lung-cancer.pdf"},{"key":"pone.0332292.ref002","volume-title":"State of Lung Cancer 2023 Report","author":"American Lung Association","year":"2023"},{"key":"pone.0332292.ref003","unstructured":"American Cancer Society. Key Statistics for Lung Cancer. [Cited 2025 January 20]. https:\/\/www.cancer.org\/cancer\/types\/lung-cancer\/about\/key-statistics.html"},{"issue":"10","key":"pone.0332292.ref004","doi-asserted-by":"crossref","first-page":"1563","DOI":"10.1158\/1055-9965.EPI-19-0221","article-title":"Cancer progress and priorities: Lung cancer","volume":"28","author":"MB Schabath","year":"2019","journal-title":"Cancer Epidemiology, Biomarkers & Prevention"},{"issue":"11","key":"pone.0332292.ref005","doi-asserted-by":"crossref","first-page":"1307","DOI":"10.1089\/jwh.2018.7397","article-title":"Lung Cancer Among Women in the United States","volume":"27","author":"SJ Henley","year":"2018","journal-title":"J Womens Health (Larchmt)"},{"key":"pone.0332292.ref006","unstructured":"American Cancer Society. Lung Cancer Kills More People Worldwide Than Other Cancer Types. [Cited 2025 January 20]. https:\/\/www.cancer.org\/research\/acs-research-news\/lung-cancer-kills-more-people-worldwide-than-other-cancers.html"},{"key":"pone.0332292.ref007","doi-asserted-by":"crossref","first-page":"1004102","DOI":"10.3389\/fonc.2022.1004102","article-title":"Financial toxicity in lung cancer","volume":"12","author":"M Boulanger","year":"2022","journal-title":"Front Oncol"},{"issue":"4","key":"pone.0332292.ref008","doi-asserted-by":"crossref","first-page":"465","DOI":"10.1001\/jamaoncol.2022.7826","article-title":"Estimates and projections of the global economic cost of 29 cancers in 204 countries and territories from 2020 to 2050","volume":"9","author":"S Chen","year":"2023","journal-title":"JAMA Oncology"},{"issue":"1","key":"pone.0332292.ref009","doi-asserted-by":"crossref","first-page":"1951963","DOI":"10.1080\/20018525.2021.1951963","article-title":"Direct and indirect economic burden of lung cancer in Denmark a nationwide study","volume":"8","author":"A Gouliaev","year":"2021","journal-title":"Eur Clin Respir J"},{"issue":"1","key":"pone.0332292.ref010","article-title":"POSC95 The Economic Burden of Lung Cancer in China: A Systematic Literature Review","volume":"25","author":"J Li","year":"2022","journal-title":"Value in Health"},{"issue":"3","key":"pone.0332292.ref011","article-title":"The impact of social determinants of health, namely financial assistance, on overall survival in advanced-stage non-small cell lung cancer patients","volume":"15","author":"A Bello","year":"2023","journal-title":"Cureus"},{"issue":"3","key":"pone.0332292.ref012","doi-asserted-by":"crossref","first-page":"612","DOI":"10.3390\/cancers16030612","article-title":"Social and Biological Determinants in Lung Cancer Disparity","volume":"16","author":"BA Brock","year":"2024","journal-title":"Cancers (Basel)"},{"key":"pone.0332292.ref013","doi-asserted-by":"crossref","first-page":"1285419","DOI":"10.3389\/fpubh.2023.1285419","article-title":"Social determinants of health and lung cancer surgery: a qualitative study","volume":"11","author":"DK Teteh","year":"2023","journal-title":"Front Public Health"},{"issue":"6","key":"pone.0332292.ref014","doi-asserted-by":"crossref","first-page":"3758","DOI":"10.21037\/jtd-20-3181","article-title":"Narrative review of socioeconomic and racial disparities in the treatment of early stage lung cancer","volume":"13","author":"N 3rd Evans","year":"2021","journal-title":"J Thorac Dis"},{"key":"pone.0332292.ref015","unstructured":"S. o. L. C. A, American Lung Association. Racial and ethnic disparities. [Cited 2025 January 20]. https:\/\/www.lung.org\/research\/state-of-lung-cancer\/racial-and-ethnic-disparities"},{"issue":"2","key":"pone.0332292.ref016","doi-asserted-by":"crossref","DOI":"10.1001\/jamanetworkopen.2019.21653","article-title":"Association of Medicaid Expansion Under the Affordable Care Act With Insurance Status, Cancer Stage, and Timely Treatment Among Patients With Breast, Colon, and Lung Cancer","volume":"3","author":"SU Takvorian","year":"2020","journal-title":"JAMA Netw Open"},{"issue":"1","key":"pone.0332292.ref017","doi-asserted-by":"crossref","DOI":"10.1001\/jamanetworkopen.2023.51529","article-title":"Medicaid Expansion Under the Affordable Care Act and Early Mortality Following Lung Cancer Surgery","volume":"7","author":"LM Nogueira","year":"2024","journal-title":"JAMA Netw Open"},{"issue":"8","key":"pone.0332292.ref018","doi-asserted-by":"crossref","first-page":"779","DOI":"10.1093\/jnci\/djaa043","article-title":"The Affordable Care Act\u2019s Medicaid Expansion and Impact Along the Cancer-Care Continuum: A Systematic Review","volume":"112","author":"HA Moss","year":"2020","journal-title":"J Natl Cancer Inst"},{"key":"pone.0332292.ref019","unstructured":"Public Policy Institute of California. Medi-Cal expansion has reduced financial barriers to needed health care. [Cited 2025 January 20]. https:\/\/www.ppic.org\/blog\/medi-cal-expansion-has-reduced-financial-barriers-to-needed-health-care\/"},{"key":"pone.0332292.ref020","doi-asserted-by":"crossref","first-page":"115609","DOI":"10.1016\/j.amjsurg.2023.12.021","article-title":"The impact of the affordable care act on access to bariatric surgery in Maryland","volume":"235","author":"OA Akinyemi","year":"2024","journal-title":"Am J Surg"},{"issue":"11","key":"pone.0332292.ref021","article-title":"Medicaid Expansion and Mortality Among Patients With Breast, Lung, and Colorectal Cancer","volume":"3","author":"MB Lam","year":"2020","journal-title":"JAMA Network Open"},{"key":"pone.0332292.ref022","volume-title":"SEER Databases in SEER*Stat","author":"S. NCI","year":"2025"},{"key":"pone.0332292.ref023","article-title":"Impact of Medicaid expansion on lung cancer survival outcomes: A difference-in-differences analysis","author":"O Akinyemi","year":"2025","journal-title":"medRxiv"},{"issue":"8","key":"pone.0332292.ref024","doi-asserted-by":"crossref","first-page":"1289","DOI":"10.1001\/jamaoncol.2020.1040","article-title":"Association of Medicaid Expansion Under the Patient Protection and Affordable Care Act With Non-Small Cell Lung Cancer Survival","volume":"6","author":"Y Liu","year":"2020","journal-title":"JAMA Oncol"},{"key":"pone.0332292.ref025","article-title":"Medicaid expansion in Texas: What\u2019s at stake?","volume-title":"The Commonwealth Fund","author":"SR Collins","year":"2016"},{"issue":"9","key":"pone.0332292.ref026","doi-asserted-by":"crossref","first-page":"5604","DOI":"10.21037\/jtd-24-786","article-title":"Impact of Medicaid expansion under the Patient Protection and Affordable Care Act on lung cancer care in the US","volume":"16","author":"AC Salami","year":"2024","journal-title":"J Thorac Dis"},{"key":"pone.0332292.ref027","doi-asserted-by":"crossref","first-page":"100292","DOI":"10.1016\/j.jcpo.2021.100292","article-title":"Evaluating Medicaid expansion benefits for patients with cancer: National Cancer Database analysis and systematic review","volume":"29","author":"NH Nathan","year":"2021","journal-title":"J Cancer Policy"},{"issue":"6","key":"pone.0332292.ref028","doi-asserted-by":"crossref","first-page":"3758","DOI":"10.21037\/jtd-20-3181","article-title":"Narrative review of socioeconomic and racial disparities in the treatment of early stage lung cancer","volume":"13","author":"N 3rd Evans","year":"2021","journal-title":"J Thorac Dis"},{"issue":"5","key":"pone.0332292.ref029","doi-asserted-by":"crossref","first-page":"461","DOI":"10.1177\/1077558718808709","article-title":"The Effect of the Affordable Care Act Medicaid Expansion on Disparities in Access to Care and Health Status","volume":"77","author":"H Lee","year":"2020","journal-title":"Medical Care Research and Review"},{"issue":"6","key":"pone.0332292.ref030","doi-asserted-by":"crossref","first-page":"863","DOI":"10.1001\/jamaoncol.2022.0159","article-title":"Association of Medicaid Expansion With Mortality Disparity by Race and Ethnicity Among Patients With De Novo Stage IV Breast Cancer","volume":"8","author":"C Malinowski","year":"2022","journal-title":"JAMA Oncology"},{"issue":"8","key":"pone.0332292.ref031","doi-asserted-by":"crossref","first-page":"962","DOI":"10.1093\/jnci\/djad094","article-title":"Changes in cancer mortality after Medicaid expansion and the role of stage at diagnosis","volume":"115","author":"JM Barnes","year":"2023","journal-title":"J Natl Cancer Inst"},{"issue":"28","key":"pone.0332292.ref032","doi-asserted-by":"crossref","first-page":"3118","DOI":"10.1200\/JCO.2014.55.6258","article-title":"Disparities in stage at diagnosis, treatment, and survival in nonelderly adult patients with cancer according to insurance status","volume":"32","author":"GV Walker","year":"2014","journal-title":"J Clin Oncol"},{"issue":"12","key":"pone.0332292.ref033","doi-asserted-by":"crossref","first-page":"1713","DOI":"10.1001\/jamaoncol.2018.3467","article-title":"Comparison of insurance status and diagnosis stage among patients with newly diagnosed cancer before vs after implementation of the Patient Protection and Affordable Care Act","volume":"4","author":"X Han","year":"2018","journal-title":"JAMA Oncology"},{"issue":"3","key":"pone.0332292.ref034","doi-asserted-by":"crossref","first-page":"247","DOI":"10.1001\/jamaoto.2019.4310","article-title":"Association of Medicaid Expansion Under the Affordable Care Act With Stage at Diagnosis and Time to Treatment Initiation for Patients With Head and Neck Squamous Cell Carcinoma","volume":"146","author":"HM Sineshaw","year":"2020","journal-title":"JAMA Otolaryngol Head Neck Surg"},{"issue":"7","key":"pone.0332292.ref035","doi-asserted-by":"crossref","first-page":"671","DOI":"10.1093\/jnci\/djaa048","article-title":"Health insurance coverage disruptions and cancer care and outcomes: systematic review of published research","volume":"112","author":"KR Yabroff","year":"2020","journal-title":"J Natl Cancer Inst"},{"issue":"7","key":"pone.0332292.ref036","doi-asserted-by":"crossref","first-page":"956","DOI":"10.1377\/hlthaff.2023.00035","article-title":"Medicaid Expansion Associated With Increase In Palliative Care For People With Advanced-Stage Cancers","volume":"42","author":"X Han","year":"2023","journal-title":"Health Aff (Millwood)"},{"issue":"9","key":"pone.0332292.ref037","doi-asserted-by":"crossref","first-page":"733","DOI":"10.2217\/cer-2020-0178","article-title":"Is Medicaid expansion associated with increases in palliative treatments for metastatic cancer?","volume":"10","author":"AP Cole","year":"2021","journal-title":"J Comp Eff Res"},{"issue":"1","key":"pone.0332292.ref038","article-title":"Medicaid expansion and variability in mortality in the USA: a national, observational cohort study","author":"BP JL Lee","year":"2022","journal-title":"The Lancet Public Health"},{"issue":"13","key":"pone.0332292.ref039","doi-asserted-by":"crossref","DOI":"10.1002\/cam4.7461","article-title":"Effect of Medicaid expansion on cancer treatment and survival among Medicaid beneficiaries and the uninsured","volume":"13","author":"KM Primm","year":"2024","journal-title":"Cancer Med"},{"issue":"9","key":"pone.0332292.ref040","doi-asserted-by":"crossref","first-page":"593","DOI":"10.6004\/jnccn.2024.7041","article-title":"Association of Medicaid Expansion With Timely Receipt of Treatment and Survival Among Patients With HR-Negative, HER2-Positive Breast Cancer","volume":"22","author":"KS Shi","year":"2024","journal-title":"J Natl Compr Canc Netw"},{"key":"pone.0332292.ref041","doi-asserted-by":"crossref","first-page":"47","DOI":"10.1200\/OP.2024.20.10_suppl.47","article-title":"Associations of Medicaid expansion with stage at diagnosis, timely initiation and receipt of guideline-concordant treatment, and survival among individuals newly diagnosed with non-small cell lung cancer.","volume":"20","author":"J Zhao","year":"2024","journal-title":"JCO Oncol Pract"},{"issue":"12","key":"pone.0332292.ref042","doi-asserted-by":"crossref","first-page":"1714","DOI":"10.1093\/jnci\/djab135","article-title":"Early Medicaid Expansion and Cancer Mortality","volume":"113","author":"JM Barnes","year":"2021","journal-title":"J Natl Cancer Inst"},{"issue":"7","key":"pone.0332292.ref043","doi-asserted-by":"crossref","first-page":"6362","DOI":"10.3390\/curroncol30070469","article-title":"The impact of medicaid expansion on patients with cancer in the United States: A review","volume":"30","author":"A Hotca","year":"2023","journal-title":"Curr Oncol"},{"issue":"7","key":"pone.0332292.ref044","doi-asserted-by":"crossref","first-page":"956","DOI":"10.1377\/hlthaff.2023.00035","article-title":"Medicaid expansion associated with increase in palliative care for people with advanced-stage cancers","volume":"42","author":"X Han","year":"2023","journal-title":"Health Aff (Millwood)"}],"container-title":["PLOS One"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0332292","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,9]],"date-time":"2026-04-09T17:39:10Z","timestamp":1775756350000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0332292"}},"subtitle":[],"editor":[{"given":"Wonsuk","family":"Yoo","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,4,9]]},"references-count":44,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2026,4,9]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0332292","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,9]]}}}