North Carolina’s implementation of Medicaid expansion in 2023 marks a pivotal shift in the state’s health policy landscape. One of the Healthy North Carolina 2030 (HNC) Report’s health indicators, Uninsured Rates, underscores the prioritization of achieving comprehensive, high quality, and affordable health insurance.1 By becoming the 40th state to expand Medicaid under the Affordable Care Act, North Carolina has closed a longstanding coverage gap affecting low-income adults, underscoring the ongoing efforts to achieve affordable health care coverage.2 The implications extend beyond insurance enrollment numbers. Increasing evidence suggests that Medicaid expansion is associated with measurable reductions in cancer mortality, largely through earlier diagnosis and improved access to treatment.3
National analyses provide important context. Early Medicaid expansion states experienced statistically significant reductions in cancer mortality compared to non-expansion states, with one study estimating a decrease of 3.07 cancer deaths per 100,000 people and more than 5000 deaths averted during the study period.3 Additional research published in the Journal of the National Cancer Institute found steeper declines in cancer mortality in early expansion states relative to non-expansion states.4 Evidence also indicates that approximately 60% of mortality reductions were mediated by decreases in distant-stage diagnoses, underscoring the importance of early detection.5
For North Carolina, where rural hospital closures, cancer disparities, and insurance gaps have intersected for years, Medicaid expansion presents both an opportunity and a test: can expanded coverage translate into measurable improvements in cancer outcomes across diverse communities? This blog examines the evidence linking Medicaid expansion to improve cancer outcomes and considers its implications for North Carolina’s health system and population health goals.
Research demonstrates that Medicaid expansion is associated with reductions in cancer mortality. One of the primary mechanisms behind this trend is a decrease in late-stage cancer diagnoses. When individuals gain insurance coverage, they are more likely to access preventive services and seek care earlier. This shift indicates diagnoses during earlier stages, where treatment is more effective and survival rates are higher.
Comparisons between early expansion states and non-expansion states further reinforce this pattern. A recent study revealed that while both expansion and non-expansion states have been seeing a drop in cancer mortality, expansion states reported a 14.6% lower mortality rate per 100,000 people in comparison to non-expansion states. Expansion states experienced steeper declines in cancer mortality over time, suggesting that access to insurance plays a direct role in improving outcomes.6 These findings highlight a fundamental insight into cancer outcomes, where survival is not determined solely by a patient’s diagnosis, but also by access to timely and appropriate care.
Insurance coverage influences cancer outcomes through several interconnected pathways by increasing access to preventive services, including routine screenings such as mammograms, colonoscopies, and lung cancer screening for high-risk individuals. These screenings are critical for detecting cancer at earlier, more treatable stages, and are even required by the Affordable Care Act (ACA) in most private health insurance plans.7
Insurance facilitates consistent access to primary care since regular interactions with health care providers increase the likelihood that symptoms are recognized and evaluated early. Without coverage, many individuals delay care until symptoms become severe, often resulting in advanced-stage diagnoses. In some cancers such as melanoma, which often presents as benign lesions until later stages that are highly metastatic, early diagnosis is critical for increased survival rates.8 A study conducted by Queen’s University further corroborates that even a one-month delay in treatment can severely increase the mortality rate. A one-month delay in surgery increased risk of death by 6%–8%, and a one-month delay in radiation therapy for head and neck cancer patients resulted in a 9% increased risk of death.9
Another important implication of Medicaid expansion is its reduction of financial toxicity, which refers to the “adverse financial consequences of cancer treatment as a form of treatment-related toxicity."10 The cost of treatment can be overwhelming, particularly for low-income populations. It was reported that 17.8% of individuals with debt in 2020 were associated with medical costs, primarily among low-income zip code regions, and patients with cancer are 2.65 times more likely to experience bankruptcy than people without cancer.10 However, by lowering out-of-pocket costs, expansion helps patients initiate and complete treatment, as demonstrated by studies that report that patients in expansion states had increased engagement with preventative services and screenings.11 Expanded coverage improves access to specialized care, including oncology services. Cancer treatment is complex and resource-intensive, requiring coordination across multiple providers, where insurance reduces barriers to receiving these services.
While Medicaid expansion improves overall access, its impact on health equity is especially important in North Carolina. Cancer disparities remain pronounced across race, income, and geography. People of color with a history of cancer often face disproportionately high health care costs and barriers to social, environmental, and economic care.12 Rural populations encounter additional challenges, including limited provider availability and hospital closures.
Expanding Medicaid has the potential to reduce some of these disparities by increasing coverage among historically underserved populations. In a study done to evaluate the impact of expansion on cancer treatment disparity, it was demonstrated that Medicaid expansion was associated with a reduction in Black-White racial disparities in association with timely systemic treatment of cancers.13 However, insurance alone does not eliminate structural inequities. Access to care is shaped by transportation, provider availability, systemic bias, and socioeconomic conditions. Without addressing these factors, disparities in cancer outcomes may persist even in the context of expanded coverage.
Emerging research also highlights disparities in outcomes among LGBTQ+ individuals with a history of cancer in North Carolina, particularly in areas such as mental health, discrimination, and access to supportive services.14 Site-specific analyses demonstrate an increased incidence of thyroid cancers among lesbian women in comparison to heterosexual women, indicating a disproportionate burden of cancer incidence associated with sexual minority populations.15 These findings underscore the need for a more comprehensive and inclusive approach to cancer care.
The success of Medicaid expansion in North Carolina will depend on how effectively it is implemented and evaluated. First, it will be essential to track changes in cancer stage at diagnosis and mortality trends over time. These metrics provide direct insight into whether earlier detection and improved outcomes are being achieved. Longitudinal analyses are needed to assess how expansion affects disparities across race, geography, and income to ensure increased granularity into the improvements in overall outcomes.16 In addition, Medicaid expansion should be aligned with broader cancer control strategies. This includes strengthening screening programs, improving care coordination, and expanding access to oncology services in underserved areas. Finally, there is a need to invest in supportive services that extend beyond clinical care. Mental health services, community-based programs, and patient navigation systems all play a role in improving cancer outcomes, particularly for vulnerable populations.
Medicaid expansion represents a critical opportunity to improve cancer outcomes in North Carolina. The evidence demonstrates that increasing access to health insurance leads to earlier diagnoses, better treatment access, and lower cancer mortality. However, coverage alone is not a complete solution. To fully integrate the benefits of expansion, policymakers and health care systems must address the broader structural factors that shape access to care to achieve meaningful and equitable improvements in cancer outcomes.
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Written by
Roshni Arun
Editorial Fellow, NCMJ
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This blog post is part of a NCIOM blog post series to explore the impacts of federal policy changes on Medicaid funding and key health indicators from the Healthy North Carolina 2030 framework.
Federal and State Policy Change Impacts on Third Grade Reading in North Carolina (March 26, 2026)
How Federal Changes to Medicaid Funding Could Impact Cancer Treatment in North Carolina (February 4, 2026)
What Medicaid Cuts Mean for NC Children and Families (November 17, 2025)
Federal Changes to Food Assistance in North Carolina (September 15, 2025)
Drug Overdose Trends in North Carolina and Potential Impacts of the One Big Beautiful Bill Act (OBBBA) (August 25, 2025)
Impacts of Changing Federal Policy on Insurance Rates and Access to Primary Care (July 31, 2025)
Primer: Understanding Private Health Insurance in North Carolina (December 30, 2025)
Primer: Understanding Medicare in North Carolina (December 30, 2025)
Primer: Understanding Medicaid in North Carolina (December 30, 2025)