State-Level Tax Policy, Cancer Screening, and Mortality Rates in the US.

Importance: The Healthy People 2030 initiative has set national cancer screening targets for breast, colon, and cervical cancers, as well as aims for reducing cancer mortality. State-level tax policy is an underappreciated social determinant of health that may improve cancer screening and mortality rates. Objective: To define the association of tax revenue and tax progressivity with state-level cancer screening and mortality. Design, Setting, and Participants: This ecologic, population-based, cross-sectional study assessed cancer screening (2020 and 2022) and mortality rates (1999-2021) in the US relative to state-level tax revenue (1997-2019) and tax progressivity (2002, 2009, 2012, 2014, and 2018) with a 2-year lag. The study included 50 states through 23 years with state-years used as the unit of analysis. Cancer screening rates were derived from the Centers for Disease Control and Prevention (CDC) Population Level Analysis and Community Estimates database. State-level cancer-related death and population counts were derived from the CDC Wide-Ranging Online Data for Epidemiologic Research database. Data analysis occurred from September to January 2024. Exposure: State-level tax policy was proxied by tax revenue per capita and the Suits index of tax progressivity, with progressive taxation equaling lower tax burden for more disadvantaged populations. Main Outcomes and Measures: Outcomes included screening rates for colon, breast, and cervical cancer, as well as mortality rates for all malignant neoplasms and malignant neoplasms with guideline-recommended screening. Multivariable models were adjusted for tax-related, socioeconomic, and demographic variables. Results: In total, 1150 state-years were included in the analysis. Median (IQR) tax revenue per capita was $4432 ($3862-$5210), and the median (IQR) number of cancer-related deaths was 8341 (3150-13 585) across all state-years. Of note, each $1000 increase in tax revenue per capita was associated with a 1.61% (95% CI, 0.50%-2.73%) increase in colorectal cancer screening, 2.17% (95% CI, 1.39%-2.96%) increase in breast cancer screening, and 0.72% (95% CI, 0.34%-1.10%) increase in cervical cancer screening rate. For malignant neoplasms with guideline-recommended screening, each $1000 increase in tax revenue per capita was associated with a decreased cancer mortality rate among White (adjusted incidence rate ratio, 0.95, 95% CI, 0.93-0.98), but not racial and ethnic minority (adjusted incidence rate ratio, 0.99, 95% CI, 0.97-1.02) populations. Conclusions and Relevance: In this cross-sectional study, tax policy was associated with increased state-level cancer screening rates, as well as decreased cancer mortality rates, which mostly benefited White populations, suggesting that state-level policies may contribute to bridging ongoing cancer care gaps.