An umbrella review of the effectiveness of fiscal and pricing policies on food and non-alcoholic beverages to improve health.

Poor quality diets represent major risk factors for the global burden of disease. Modeling studies indicate a potential for diet-related fiscal and pricing policies (FPs) to improve health. There is real-world evidence (RWE) that such policies can change behavior; however, the evidence regarding health is less clear. We conducted an umbrella review of the effectiveness of FPs on food and non-alcoholic beverages in influencing health or intermediate outcomes like consumption. We considered FPs applied to an entire population within a jurisdiction and included four systematic reviews in our final sample. Quality appraisal, an examination of excluded reviews, and a literature review of recent primary studies assessed the robustness of our results. Taxes and, to some extent, subsidies are effective in changing consumption of taxed/subsidized items; however, substitution is likely to occur. There is a lack of RWE supporting the effectiveness of FPs in improving health but this does not mean that they are ineffective. FPs may be important for improving health but their design is critical. Poorly designed FPs may fail to improve health and could reduce support for such policies or be used to support their repeal. More high-quality RWE on the impact of FPs on health is needed.

An umbrella review of the acceptability of fiscal and pricing policies to reduce diet-related noncommunicable disease.

CONTEXT: Poor diet has been implicated in a range of noncommunicable diseases. Fiscal and pricing policies (FPs) may offer a means by which consumption of food and non-alcoholic beverages with links to such diseases can be influenced to improve public health. OBJECTIVE: To examine the acceptability of FPs to reduce diet-related noncommunicable disease, based on systematic review evidence. DATA SOURCES: MEDLINE, EMBASE, PsychInfo, SCI, SSCI, Web of Science, Scopus, EconLit, the Cochrane Library, Epistemonikos, and the Campbell Collaboration Library were searched for relevant studies published between January 1, 1990 and June 2021. DATA EXTRACTION: The studies included systematic reviews of diet-related FPs and: used real-world evidence; examined real or perceived barriers/facilitators; targeted the price of food or non-alcoholic beverages; and applied to entire populations within a jurisdiction. A total of 9996 unique relevant records were identified, which were augmented by a search of bibliographies and recommendations from an external expert advisory panel. Following screening, 4 systematic reviews remained. DATA ANALYSIS: Quality appraisal was conducted using the AMSTAR 2 tool. A narrative synthesis was undertaken, with outcomes grouped according to the WHO-INTEGRATE criteria. The findings indicated a paucity of high-quality systematic review evidence and limited public support for the use of FPs to change dietary habits. This lack of support was related to a number of factors that included: their perceived potential to be regressive; a lack of transparency, ie, there was mistrust around the use of revenues raised; a paucity of evidence around health benefits; the deliberate choice of rates that were lower than those considered necessary to affect diet; and concerns about the potential of such FPs to harm economic outcomes such as employment. CONCLUSION: The findings underscore the need for high-quality systematic review evidence on this topic, and the importance of responding to public concerns and putting in place mechanisms to address these when implementing FPs. This study was funded by Safefood [02A-2020]. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration no. CRD42021274454.

The effect of beverage taxes on youth consumption and body mass index: Evidence from Mauritius.

Taxes on sugar-sweetened beverages (SSBs) are relatively new and there is limited evidence about their impact on SSB consumption or body mass index (BMI) (as opposed to prices, purchases, or sales), their impact on youth (as opposed to adults), or their impact in non-Western nations. This paper adds to the evidence across all these dimensions by estimating the effect of an SSB tax on SSB consumption and the BMI of youth in Mauritius, an island nation in the Indian Ocean, which we compare to Maldives, another island nation which did not implement an SSB tax during the time of our data. Results of difference-in-differences models indicate that the tax in Mauritius had no detectable impact on the consumption of SSBs or the BMI of the pooled sample of boys and girls. However, models estimated separately by sex indicate that the probability that boys consumed SSBs fell by 9.4 percentage points (11%). These are among the first estimates of the effect of SSB taxes on youth consumption and contribute to the limited evidence on the impact of SSB taxes on weight, and in non-Western countries.

Disparities in exposure to television advertising of sugar-sweetened and non-nutritive sweetened beverages among U.S. adults and teens, 2007-2013.

The objective of this study was to estimate disparities in exposure to television advertising of sugar-sweetened and non-nutritive sweetened beverages among U.S. adults and teens. Data (2007-2013) came from the National Consumer Survey and included 115,510 adult respondents (age 18+) and 8635 teen respondents (age 12-17). The data was originally accessed in 2018 and analyzed in 2019-2020. The main outcomes were individual-level estimated exposure to advertisements for regular soda, diet soda, and energy/sport drinks. The main exposures were by race/ethnicity, household income, and educational attainment. Non-white adults (teens) were exposed to an estimated (per year) 101.5 (190.1) regular soda ads, 49.5 (61.2) diet soda ads, and 157.1 (279.6) energy/sport ads per year while white respondents were exposed to 97.5 (127.7) regular soda ads, 45.8 (44.2) diet soda ads, and 123.9 (192.0) energy/sport ads per year. Adult (teen) respondents who were non-white with low incomes and with low educational attainment were exposed to 4.7% (53.7%) more regular soda ads, 6.6% (43.8%) more diet ads, and 23.2% (56.2%) more energy/sport ads than respondents who were white with high incomes and high educational attainment. Demographic and socio-economic groups with a higher prevalence of obesity were exposed to significantly more advertisements for sugar-sweetened beverages. When evaluating potential policies to regulate marketing of sugar-sweetened and non-nutritive sweetened beverages, policymakers should consider the disparate exposure of at-risk populations to advertising of sugar-sweetened and non-nutritive sweetened beverages.

Job Absenteeism Costs of Obesity in the United States: National and State-Level Estimates.

OBJECTIVE: To estimate the causal effect of obesity on job absenteeism and the associated lost productivity in the United States, both nationwide and by state. METHODS: We conducted a retrospective pooled cross-sectional analysis using the 2001 to 2016 Medical Expenditure Panel Survey and estimated two-part models of instrumental variables. RESULTS: Obesity, relative to normal weight, raises job absenteeism due to injury or illness by 3.0 days per year (128%). Annual productivity loss due to obesity ranges from $271 to $542 (lower/upper bound) per employee with obesity, with national productivity losses ranging from $13.4 to $26.8 billion in 2016. Trends in state-level estimates mirror those at the national level, varying across states. CONCLUSIONS: Obesity significantly raises job absenteeism. Reductions in job absenteeism should be included when calculating the cost-effectiveness of interventions to prevent or reduce obesity among employed adults.

Direct medical costs of obesity in the United States and the most populous states.

BACKGROUND: After a dramatic increase in prevalence over several decades, obesity has become a major public health crisis in the United States. Research to date has consistently demonstrated a correlation between obesity and higher medical costs for a variety of U.S. subpopulations and specific categories of care. However, by examining associations rather than causal effects, previous studies likely underestimated the effect of obesity on medical expenditures. OBJECTIVE: To estimate the causal effect of obesity on direct medical care costs at the national and state levels. METHODS: This study is a pooled cross-sectional analysis of retrospective data from the 2001-2016 Medical Expenditure Panel Surveys. Adults aged 20-65 years with a biological child living in the household were included in the study sample. Primary outcomes were individual-level medical expenditures due to obesity, overall, as well as separately by type of payer and category of medical care. Results were reported at the national level and separately for the 20 most populous states. The expenditure estimates were obtained from 2-part models of instrumental variables in which the respondent's body mass index (BMI) was instrumented using the BMI of their biological child. RESULTS: Adults with obesity in the United States compared with those with normal weight experienced higher annual medical care costs by $2,505 or 100%, with costs increasing significantly with class of obesity, from 68.4% for class 1 to 233.6% for class 3. The effects of obesity raised costs in every category of care: inpatient, outpatient, and prescription drugs. Increases in medical expenditures due to obesity were higher for adults covered by public health insurance programs ($2,868) than for those having private health insurance ($2,058). In 2016, the aggregate medical cost due to obesity among adults in the United States was $260.6 billion. The increase in individual-level expenditures due to obesity varied considerably by state (e.g., 24.0% in Florida, 66.4% in New York, and 104.9% in Texas). CONCLUSIONS: The 2-part models of instrumental variables, which estimate the causal effects of obesity on direct medical costs, showed that the effect of obesity is greater than suggested by previous studies, which estimated only correlations. Much of the aggregate national cost of obesity-$260.6 billion-represents external costs, providing a rationale for interventions to prevent and reduce obesity. DISCLOSURES: Novo Nordisk financed the development of the study design, analysis, and interpretation of data, as well as writing support of the manuscript. Cawley, Biener, and Meyerhoefer received financial support from Novo Nordisk to conduct the research study on which this manuscript is based. Smolarz and Ramasamy are employees of Novo Nordisk. Ding and Zvenyach have no conflicts to declare. Our research has been presented as a poster at the 2020 Academy Health Annual Research Meeting (Virtual), July 28-August 6, 2020.

Oakland's sugar-sweetened beverage tax: Impacts on prices, purchases and consumption by adults and children.

Several cities in the U.S. have implemented taxes on sugar-sweetened beverages (SSBs) in an attempt to improve public health and raise revenue. On July 1, 2017, Oakland introduced a tax of one cent per ounce on SSBs. In this paper, we estimate the impact of the tax on retail prices, product availability, purchases, and child and adult consumption of taxed beverages in Oakland, as well as of potential substitute beverages. We collected data from Oakland stores and their customers and a matched group of stores in surrounding counties and their customers. We collected information in the months prior to the implementation of the tax and again a year later on: (1) prices, (2) purchase information from customers exiting the stores, and (3) a follow-up household survey of adults and child beverage purchases and consumption. We use a difference-in-differences identification strategy to estimate the impact of the tax on prices, purchases, and consumption of taxed beverages. We find that roughly 60 percent of the tax was passed on to consumers in the form of higher prices. There was a slight decrease in the volume of SSBs purchased per shopping trip in Oakland and a small increase in purchases at stores outside of the city, resulting in a decrease in purchases of 11.33 ounces per shopping trip that is not statistically significant. We find some evidence of increased shopping by Oakland residents at stores outside of the city. We do not find evidence of substantial changes in the overall consumption of SSBs or of added sugars consumed through beverages for either adults or children after the tax.

The medical care costs of obesity and severe obesity in youth: An instrumental variables approach.

This paper is the first to use the method of instrumental variables to estimate the impact of obesity and severe obesity in youth. on U.S. medical care costs. We examine data from the Medical Expenditure Panel Survey for 2001-2015 and instrument for child BMI using the BMI of the child's biological mother. Instrumental variables estimates indicate that obesity in youth raises annual medical care costs by $907 (in 2015 dollars) or 92%, which is considerably higher than previous estimates of the association of youth obesity with medical costs. We find that obesity in youth significantly raises costs in all major categories of medical care: outpatient doctor visits, inpatient hospital stays, and prescription drugs. The costs of youth obesity are borne almost entirely by third-party payers, which is consistent with substantial externalities of youth obesity, which in turn represents an economic rationale for government intervention.

The impact of sugar-sweetened beverage taxes on purchases: Evidence from four city-level taxes in the United States.

Since 2017, many US cities have implemented taxes on sugar-sweetened beverages to decrease consumption of sugary beverages and raise revenue. We analyze household receipt data to examine the impact of taxes on households' beverage purchases in the four largest US cities with such taxes: Philadelphia, PA; San Francisco, CA; Seattle, WA; and Oakland, CA. We compare changes in monthly household purchases in the treatment cities with changes in two comparison groups: (1) areas adjacent to the treatment cities or (2) a matched set of households nationally. An increase in the tax rate of 1 cent per ounce decreases household purchases of taxed beverages by 53.0 ounces per month (12.2%). This impact is consistent with a reduction in individual consumption of 5 calories per day per household member and eventual reduction in weight of 0.5 pounds. However, the decline was concentrated in Philadelphia, where the tax decreased purchases by 27.7%. There was no change in purchases of taxed beverages in the other three cities combined.

The impact of the Philadelphia beverage tax on purchases and consumption by adults and children.

Numerous U.S. cities have recently enacted taxes on sweetened beverages. To examine the effects of the beverage tax of 1.5 cents per ounce in Philadelphia, we surveyed adults and children in Philadelphia and nearby comparison communities both before the tax and nearly one year after implementation. We find that the tax reduced purchases in Philadelphia stores and that Philadelphia residents increased purchases of taxed beverages outside of the city. The tax reduced the frequency of adults' soda consumption by 31 percent, but had no detectable impacts on adults' consumption of other beverages. The tax had no detectable impact on children's consumption of soda or all taxed beverages, although children who were frequent consumers prior to the tax reduced their consumption after the tax.

The Economics of Taxes on Sugar-Sweetened Beverages: A Review of the Effects on Prices, Sales, Cross-Border Shopping, and Consumption.

During the past decade, dozens of countries, regions, and cities have enacted taxes on sugar-sweetened beverages (SSBs). They have been primarily motivated by a desire to raise prices, reduce sales and consumption, improve population health, and raise revenue. This review outlines the economic rationale for SSB taxes and illustrates their predicted effects. It reviews the research on the effects of these taxes on retail prices, sales, cross-border shopping, consumption, and product availability. The evidence indicates that the amount by which taxes increase retail prices (also called the pass-through of the tax) varies by jurisdiction, ranging from less than 50% to 100% of the tax. Sales tend to decrease significantly in the taxing jurisdiction, although this seems to be partly offset by residents increasingly shopping outside of the taxing jurisdiction (i.e., engaging in cross-border shopping).Overall, taxes lower consumption of the taxed beverages by adults, although not for all types of beverages or all groups of consumers. We conclude with suggestions for improving the design of such taxes and directions for future research.

Gains in health insurance coverage explain variation in Democratic vote share in the 2008-2016 presidential elections.

In the last decade, health care reform has dominated U.S. public policy and political discourse. Double-digit rate increases in premiums in the Health Insurance Marketplaces established by the Affordable Care Act (ACA) in 2018 make this an ongoing issue that could affect future elections. A seminal event that changed the course of policy and politics around health care reform is the 2016 presidential election. The results of the 2016 presidential election departed considerably from polling forecasts. Given the prominence of the Affordable Care Act in the election, we test whether changes in health insurance coverage at the county-level correlate with changes in party vote share in the presidential elections from 2008 through 2016. We find that a one-percentage-point increase in county health insurance coverage was associated with a 0.25-percentage-point increase in the vote share for the Democratic presidential candidate. We further find that these gains on the part of the Democratic candidate came almost fully at the expense of the Republican (as opposed to third-party) presidential candidates. We also estimate models separately for states that did and did not expand Medicaid and find no differential effect of insurance gains on Democratic vote share for states that expanded Medicaid compared to those that did not. Our results are consistent with the hypothesis that outcomes in health insurance markets played a role in the outcome of the 2016 presidential election. The decisions made by the current administration, and how those decisions affect health insurance coverage and costs, may be important factors in future elections as well.

The effect of weight on labor market outcomes: An application of genetic instrumental variables.

This paper contributes to the literature on the labor market consequences of obesity by using a novel instrument: genetic risk score, which reflects the predisposition to higher body mass index (BMI) across many genetic loci. We estimate instrumental variable models of the effect of BMI on labor market outcomes using Finnish data that have many strengths, for example, BMI that is measured rather than self-reported, and data on earnings and social income transfers that are from administrative tax records and are thus free of the problems associated with nonresponse, reporting error or top coding. The empirical results are sensitive to whether we use a narrower or broader genetic risk score, and to model specification. For example, models using the narrower genetic risk score as an instrument imply that a one-unit increase in BMI is associated with 6.9% lower wages, 1.8% fewer years employed, and a 3 percentage point higher probability of receiving any social income transfers. However, when we use a newer, broader genetic risk score, we cannot reject the null hypothesis of no effect. Future research using genetic risk scores should examine the sensitivity of their results to the risk score used.

Third Year of Survey Data Shows Continuing Benefits of Medicaid Expansions for Low-Income Childless Adults in the U.S.

BACKGROUND: The Affordable Care Act (ACA) of 2010 incentivized states to expand eligibility for their Medicaid programs. Many did so in 2014, and there has been great interest in understanding the effects of these expansions on access to health care, health care utilization, and population health. OBJECTIVE: To estimate the longer-term (three-year) impact of Medicaid expansions on insurance coverage, access to care, preventive care, self-assessed health, and risky health behaviors. DESIGN: A difference-in-differences model, exploiting variation across states and over time in Medicaid expansion, was estimated using data from the Behavioral Risk Factor Surveillance System (BRFSS) for 2010-2016. PARTICIPANTS: Low-income childless adults aged 19-64 years in the BRFSS. MAIN MEASURES: Outcomes included insurance coverage, access to care, several forms of preventive care (e.g., routine checkups, flu shots, HIV tests, dental visits, and cancer screening), risky health behaviors (e.g., smoking, alcohol abuse, obesity), and self-assessed health. KEY RESULTS: The previously documented benefits of Medicaid expansions on insurance coverage, access to care, preventive care, and self-assessed health have persisted 3 years after expansion. There was no detectable effect on risky health behaviors. CONCLUSIONS: The Affordable Care Act was motivated in part by a desire to increase health insurance coverage, improve access to care, and increase use of preventive care. The Medicaid expansions facilitated by the ACA are helping to achieve those objectives, and the benefits have persisted 3 years after expansion.

Fiscal policy to improve diets and prevent noncommunicable diseases: from recommendations to action.

The World Health Organization has recommended that Member States consider taxing energy-dense beverages and foods and/or subsidizing nutrient-rich foods to improve diets and prevent noncommunicable diseases. Numerous countries have either implemented taxes on energy-dense beverages and foods or are considering the implementation of such taxes. However, several major challenges to the implementation of fiscal policies to improve diets and prevent noncommunicable diseases remain. Some of these challenges relate to the cross-sectoral nature of the relevant interventions. For example, as health and economic policy-makers have different administrative concerns, performance indicators and priorities, they often consider different forms of evidence in their decision-making. In this paper, we describe the evidence base for diet-related interventions based on fiscal policies and consider the key questions that need to be asked by both health and economic policy-makers. From the health sector's perspective, there is most evidence for the impact of taxes and subsidies on diets, with less evidence on their impacts on body weight or health. We highlight the importance of scope, the role of industry, the use of revenue and regressive taxes in informing policy decisions.

L'Organisation mondiale de la Santé a recommandé aux États membres d'envisager de taxer les boissons et aliments à haute teneur énergétique et/ou de subventionner les denrées riches en nutriments, en vue d'améliorer les régimes alimentaires et de prévenir les maladies non transmissibles. Aujourd'hui, nombreux sont les pays à avoir instauré des taxes sur les boissons et aliments à haute teneur énergétique ou à envisager de le faire. Néanmoins, d'importants défis subsistent pour la mise en application de ce type de politiques fiscales. Certains sont liés à la nature intersectorielle des interventions appropriées. Par exemple, comme les responsables des politiques économiques et les responsables des politiques de santé ont des préoccupations administratives, des priorités et des indicateurs de performances différents, ils s'appuient souvent sur différentes formes de données dans leur prise de décisions. Dans le présent document, nous décrivons les données probantes susceptibles d'orienter les interventions sur l'alimentation fondées sur des politiques fiscales et nous évoquons les principales problématiques auxquelles doivent répondre à la fois les responsables des politiques économiques et les responsables des politiques de santé. D'un point de vue de santé publique, les preuves de l'impact des taxes et subventions sur les habitudes alimentaires sont plus nombreuses que les preuves de leur impact sur le poids ou la santé. Nous abordons également l'importance du périmètre d'action, le rôle de l'industrie, l'utilisation des recettes fiscales et la régressivité des taxes, dans l'optique d'éclairer les décisions politiques.

La Organización Mundial de la Salud ha recomendado a los Estados Miembros considerar la posibilidad de aplicar un impuesto a las bebidas y los alimentos de alto contenido energético y/o subvencionar los alimentos ricos en nutrientes para mejorar las dietas y prevenir enfermedades no contagiosas. Numerosos países ya aplican impuestos a bebidas y alimentos de alto contenido energético o consideran la implementación de dichos impuestos. Sin embargo, persisten varios desafíos importantes para la implementación de políticas fiscales para mejorar las dietas y prevenir las enfermedades no contagiosas. Algunos de estos desafíos están relacionados con la naturaleza intersectorial de las intervenciones correspondientes. Por ejemplo, puesto que los encargados de la formulación de políticas de salud y economía tienen diferentes preocupaciones administrativas, indicadores de rendimiento y prioridades, a menudo tienen en cuenta diferentes formas de pruebas en su toma de decisiones. En este documento, se describe la base de pruebas para intervenciones relacionadas con la dieta basadas en políticas fiscales y se consideran las preguntas clave que deben formular tanto los responsables de la política económica como de la de salud. Desde la perspectiva del sector de la salud, existen muchas pruebas del impacto de los impuestos y subsidios en las dietas, con menos pruebas de sus impactos sobre el peso o la salud corporal. Se destaca la importancia del alcance, el papel de la industria, el uso de los ingresos y los impuestos regresivos para informar sobre las decisiones políticas.

Health disparities across education: The role of differential reporting error.

One of the most robust findings in health economics is that higher educated individuals tend to be in better health. This paper tests whether health disparities across education are to some extent due to differences in reporting error across education. We test this hypothesis using data from the pooled National Health and Nutrition Examination Survey (NHANES) for 1999-2012, which include both self-reports and objective verification for an extensive set of health behaviors and conditions, including smoking, obesity, high blood pressure, high cholesterol, and diabetes. We find that college graduates are more likely to give false negative reports of obesity and high total cholesterol; one possible explanation for this is social desirability bias. However, college graduates are also significantly less likely to give false positive reports of smoking, obesity, and high cholesterol. Because there are far more truly negative people (who are less likely to give a false positive report) than more truly positive people (who are more likely to give a false negative report), we find that college graduates report their health significantly more accurately overall.

The Impact of Obesity on Medical Care Costs and Labor Market Outcomes in the US.

BACKGROUND: The prevalence of obesity has risen dramatically in most countries of the world, and the economic consequences of obesity are not well understood. METHODS: We analyzed data from the Medical Expenditure Panel Survey (MEPS) for 2001-2015 and estimated the percentage of healthcare costs that were associated with adult obesity, both for the US as a whole and for the most populous states. We also reviewed the literature on the impact of obesity on economic outcomes such as medical care costs, employment, and wages. RESULTS: The percent of US national medical expenditures devoted to treating obesity-related illness in adults rose from 6.13% in 2001 to 7.91% in 2015, an increase of 29%. Substantial differences existed across states; in 2015, some states (AZ, CA, FL, NY) devoted 5%-6% of medical expenditures to obesity, whereas others (NC, OH, WI) spent >12% of all healthcare dollars on obesity. A review of previous literature that exploited natural experiments to estimate causal effects found that obesity raises medical care costs and lowers wages and the probability of employment. CONCLUSIONS: A substantial and rising percentage of healthcare costs are associated with obesity. This is true for the US, for individual states, for each category of expenditure, and for each type of payer. Previous literature generally found that obesity worsens economic outcomes, such as medical care costs, wages, and employment, and imposes negative external costs that may justify government intervention.

Policies to Prevent Obesity and Promote Healthier Diets: A Critical Selective Review.

BACKGROUND: Obesity has risen dramatically in recent decades in the US and most other countries of the world. This has led to a search for public policies and other interventions that can prevent obesity and improve diets. However, there remain considerable uncertainty and confusion about the effectiveness of many potential policies. CONTENT: This review assesses the strength of the research evidence for 4 commonly proposed policies to prevent obesity and improve diets: (a) taxes on sugar-sweetened beverages (SSBs); (b) calorie labels on restaurant menus; (c) restricting food advertising to youth; and (d) excluding energy-dense foods from the Supplemental Nutrition Assistance Program (SNAP). SUMMARY: The existing literature has many limitations. Often, the research designs are weak, with small nonrepresentative samples and only short-run follow-up. However, a number of studies are of sufficiently high quality to be informative, and on the basis of that evidence, there appears to be no magic bullet to prevent and reduce obesity. Thus, a suite of these policies may be needed for a meaningful impact.

Effect of Medicaid Expansions of 2014 on Overall and Early-Stage Cancer Diagnoses.

OBJECTIVES: To determine whether the 2014 Medicaid expansions facilitated by the Affordable Care Act affected overall and early-stage cancer diagnosis for nonelderly adults. METHODS: We used Surveillance, Epidemiology, and End Results Cancer Registry data from 2010 through 2014 to estimate a difference-in-differences model of cancer diagnosis rates, both overall and by stage, comparing changes in county-level diagnosis rates in US states that expanded Medicaid in 2014 with those that did not expand Medicaid. RESULTS: Among the 611 counties in this study, Medicaid expansion was associated with an increase in overall cancer diagnoses of 13.8 per 100 000 population (95% confidence interval [CI] = 0.7, 26.9), or 3.4%. Medicaid expansion was also associated with an increase in early-stage diagnoses of 15.4 per 100 000 population (95% CI = 5.4, 25.3), or 6.4%. There was no detectable impact on late-stage diagnoses. CONCLUSIONS: In their first year, the 2014 Medicaid expansions were associated with an increase in cancer diagnosis, particularly at the early stage, in the working-age population. Public Health Implications. Expanding public health insurance may be an avenue for improving cancer detection, which is associated with improved patient outcomes, including reduced mortality.