Despite ongoing disparities in the use of health care services among races/ethnicities and ages, as well as by insurance status, African American women with advanced breast cancer benefited the most following implementation of the Affordable Care Act (ACA) in states that chose to expand their Medicaid coverage, detail study results published online today in JAMA Surgery.
Improvements have been seen elsewhere on how the ACA has affected survival among the sickest of patients, but few studies have focused solely on the gains made in the breast cancer space, until the authors of the present study took up their investigation. Their primary objective was “to review the association of Medicaid expansion with breast cancer stage at diagnosis and the disparities associated with insurance status, age, and race/ethnicity.”
This retrospective cohort analysis enrolled 1,796,902 women, extracting data for breast cancer diagnoses made between 2007 and 2016 from the National Cancer Database and analyzing it from August 12, 2019, to January 19, 2020, for trends resulting from a comparison of primary breast cancer rates in expansion and nonexpansion states both before (2012-2013) and after (2015-2016) Medicaid expansion occurred in 2014. All participants had private insurance, Medicare, or Medicaid coverage, or they were uninsured.
“In all states and at all periods, patients with private insurance or Medicare were about half as likely to present with late-stage breast cancer compared with patients who were uninsured or had Medicaid,” the authors stated.
Four percent of the women overall (n = 71,235) were uninsured from 2012 through 2016. In expansion states, however, all races/ethnicities still witnessed a drop in their total uninsured population: from 22.6% to 13.5% (P <.001), or an almost 40.0% decrease. By contrast, nonexpansion states had a much smaller decrease in uninsured patients: 36.5% to 35.6% (P = .12), which is just a 2.5% improvement.
Within this group, from the pre- to the postexpansion period, there was an overall drop among all the states in late-stage cancer at diagnosis. Nonexpansion states saw their rate fall to 23.7% from 25.6%, whereas expansion states had a more noticeable gain of 24.4% to 21.7%.
Combining the numbers for uninsured and Medicaid coverage, however, shows a stark contrast in expansion and nonexpansion states. Another benefit seen for all races was an 11.5% drop in advanced stages of disease (stage 3 or 4) at diagnosis in expansion states (21.8% to 19.3%; P <.001), whereas nonexpansion states remained almost the same, with just a 2.9% drop (24.2% to 23.5%; P = .14).
Meanwhile, patients younger than 50 years experienced improvements in expansion states only, from 22.9% to 20.7% (P <.001), while patients 50 years and older saw decreases in late-stage disease at diagnosis in expansion and nonexpansion states: 21.3% to 18.8% (P <.001) and 23.3% to 21.5% (P <.006), respectively.
It was African American women with breast cancer, however, who had the biggest improvements in advanced-stage disease at presentation: 24.6% to 21.6% (—12.2%; P <.001) in expansion states compared with a slight uptick from 27.0% to 27.5% (1.9%; P = .94) in nonexpansion states.
“Expansion of Medicaid was associated with a reduced number of uninsured patients and a reduced incidence of advanced-stage breast cancer,” the authors concluded. “These data suggest that increasing access to health care resources may alter the distribution of breast cancer stage at diagnosis.”
They propose ongoing investigations of long-term outcomes related to ACA expansion, as data continue to come in and are analyzed.
Le Blanc JM, Heller DR, Friedrich A, Lannin DR, Park TS. Association of Medicaid expansion under the Affordable Care Act with breast cancer stage at diagnosis. JAMA Surg. Published online July 1, 2020. doi:10.1001/jamasurg.2020.1495