Patients diagnosed with invasive breast cancer in a Southern state that expanded access to Medicaid were more likely to receive treatment and less likely to be diagnosed with advanced-stage disease, according to new research published in the Journal of the American College of Surgeons (JACS).
Under the Affordable Care Act (ACA), Medicaid was expanded in 2010 to provide coverage for all adults 18 to 64 for up to 138% of the Federal Poverty Level (about $17,774 for an individual in 2021). However, in 2012, the Supreme Court made it optional for states to adopt the expansion. To date, 40 states have expanded Medicaid, with the majority of these states being located outside of the South.
"A lot of research on the Affordable Care Act has looked at trends at the national level. But if you look at a map of where states actually expanded Medicaid, the South is under-represented," said lead author Amy Laughlin, MD, MSHP, chief quality officer at the Orlando Health Cancer Institute. "We wanted to make sure that the impact of Medicaid expansion on breast cancer was assessed at the Southern state level to understand the impact specifically in that region and perhaps to inform policy for the rest of the region."
Some prior research has shown that expanded access to Medicaid can improve access to cancer screening services, such as mammograms,2 but little research has specifically compared neighboring populations in the South, where many vulnerable patients live in rural areas and have less access to affordable care, said senior author Quyen Chu, MD, MBA, FACS, a surgical oncologist with the Orlando Health Cancer Institute. In his former position at the Louisiana State University Health Sciences Center, Dr. Chu sometimes encountered patients who traveled, in search of cancer treatment, from Texas, which did not adopt the expansion, to Louisiana, which expanded Medicaid in 2016.
"Those encounters are something you don't really hear about. But, from my personal experience, that's what I saw during my time when I was practicing in Louisiana," he said. "There are vulnerable patients who don't have access to care, and we wanted to look at the facts to know whether the ACA expansion had an impact on those patients. We wanted to be apolitical about it; we didn't know the answer before doing the study."
Using the North American Association of Central Cancer Registries (NAACCR) database, the researchers identified patients on Medicaid or without insurance who were between the ages of 40-64 and diagnosed with invasive breast cancer from 2011 to 2018.
The researchers compared data from patients who lived in Southern states that expanded access to Medicaid (Louisiana, Kentucky, and Arkansas) to patients in states that did not expand access to Medicaid (Tennessee, Alabama, Mississippi, Texas, and Oklahoma). Oklahoma expanded coverage in 2020, but data from that state was included in the non-expanded group because this research only included data up until 2018.
- Among 21,974 patients, those living in states that expanded Medicaid were less likely to be uninsured than patients living in states that did not expand (18.9% vs. 41.1%).
- Compared with breast cancer patients in states that expanded Medicaid, patients in states that did not expand access were younger and more likely to be uninsured, Hispanic, and live in an urban area with less poverty.
- Patients living in a state that expanded Medicaid were less likely to be diagnosed with stage IV disease, with odds of being diagnosed with advanced-stage breast cancer decreasing by 7% every year after expansion. The authors hypothesize that this decrease may be attributed to increased access to mammogram screenings among low-income patients.
- Unrelated to Medicaid expansion, just by being diagnosed in a state that expanded Medicaid, patients had 2.27 higher odds of receiving treatment for breast cancer. "And this is regardless of expansion, so more likely due to intrinsic factors in the state," Dr. Laughlin noted. These intrinsic factors were not specifically identified in the study but could be related to other infrastructure or services available in states that expanded Medicaid, independent of policy changes.
However, the study also revealed that Medicaid may only be part of the picture when it comes to receiving quality cancer care. Even though patients diagnosed in states that expanded Medicaid were more likely to receive treatment overall, the proportion of patients undergoing treatments for their breast cancer actually decreased in all states regardless of Medicaid expansion.
"This trend raises concern," Dr. Laughlin said. "We know from other studies that cancer diagnoses are increasing. If we're then having less treatment received, are we not meeting that demand? That was a surprising finding to me."
Katharine Yao, MD, FACS, Chair of the National Accreditation Program for Breast Centers (NAPBC) of the American College of Surgeons and a surgical oncologist with NorthShore University Health System, agreed that the decline in treatment noted by the researchers is concerning. "Future studies may be warranted to understand whether this trend is due to stage migration, access issues, patient preferences, or another reason," said Dr. Yao, who was not involved with the study.
The decrease in uninsured rates in states that expanded Medicaid found in this study is striking, Dr. Yao added. "Since Medicaid expansion resulted in a greater than 50% drop in the rate of uninsured for those states that underwent expansion, it seems like a missed opportunity for those states that did not adopt Medicaid expansion," she said. "While observational and only focused on a cohort of patients, this research brings awareness to the widespread disparities in healthcare in the Southern states and how much further these states have to go before patients receive the healthcare they need."
The study represents an initial step to understand treatment patterns and was limited by the data included in the NAACCR database, the authors noted. In future studies, they hope to understand if earlier detection and increased access to care improved survival rates. Investigating potential racial or socioeconomic disparities in breast cancer treatment between states that expanded Medicaid or did not may also reveal important findings.
"As a society, we have made tremendous gains in terms of finding novel therapies, such as immunotherapy or targeted drug therapy. But the question is, how many of these patients actually benefit from those discoveries?" Dr. Chu said. "Theoretically speaking, everyone should benefit from those discoveries. For the next step, we would like to look at if we see an impact for those who live in rural areas or belong to vulnerable populations."
Study coauthors are Tingting Li, MPH; Qingzhao Yu, PhD; Xiao-Cheng Wu, MD, MPH; Yong Yi, PhD; Mei-Chin Hsieh, PhD, MSPH; William Havron, MD, FACS; and Margo Shoup, MD, MBA, FACS. All authors are affiliated with the Orlando Health Cancer Institute or the Louisiana State University Health Sciences Center.
The study authors have no relevant disclosures to report. Dr. Wu and Dr. Hsieh were supported by the National Cancer Institute under award number HHSN261201800007I/HHSN26100002.
Laughlin, A.I., et al. (2023) Impact of Medicaid Expansion on Breast Cancer Diagnosis and Treatment in Southern States. Journal of the American College of Surgeons. doi.org/10.1097/XCS.0000000000000550.