Breast Reconstruction Disparities Improve Significantly with Medicaid Expansion

October 2021, Vol 12, No 5

Medicaid expansion under the Affordable Care Act was associated with significant increases in breast reconstruction surgery among non-Hispanic black women and women with lower income and education levels, according to results of a study presented during the American Society of Breast Surgeons 22nd Annual Meeting. At times, these increases achieved parity with non-Hispanic white women.

“Overall, nearly 37% of women undergo mastectomy for the treatment of breast cancer, and among them, 21% to 38% undergo subsequent breast reconstruction,” said Kirithiga Ramalingam, MD, PGY-2 Surgery Resident, Loma Linda University Health, CA, during a press briefing at the meeting. Breast reconstruction, she noted, confers quality of life and mental health benefits.

Study Details

Medicaid expansion has been shown to reduce disparities in access to healthcare related to race, education, and income level. As a result, Dr Ramalingam and colleagues hypothesized that Medicaid expansion may mitigate disparities related to postmastectomy reconstruction in patients with breast cancer.

The study assessed the impact of the 2014 Medicaid expansion (subsequent to the 2010 enactment of the Affordable Care Act) on well-documented disparities in breast reconstruction rates. The investigators selected data from the National Cancer Database for all non-Hispanic black and non-Hispanic white patients with breast cancer aged >40 years who had a mastectomy with or without reconstructive surgery between 2010 and 2017. Through multivariable logistic regression, they evaluated associations between various factors potentially affecting reconstruction rates.

Results showed that of 443,607 patients, 36.3% (N = 161,128) had reconstruction, 13.1% (N = 58,249) were non-Hispanic black, 16.8% (N = 74,430) had median income <$40,227, and 17.1% (N = 75,718) were in the lowest education level. Patients who were younger, non-Hispanic white, had higher income or education levels, had lower comorbidity index, were insured, and had nonmetastatic disease were significantly more likely to have undergone reconstructive surgery.

Increasing rates of breast reconstruction followed the timeline of Medicaid expansion for non-Hispanic black women as well as women in lower income and education levels. In contrast, in states that did not implement expansion, lower proportions of non-Hispanic black patients had reconstructive surgery compared with non-Hispanic white patients throughout the examined time period, Dr Ramalingam said.

States were varied in the timing of their implementation of coverage expansion, and investigators categorized them as early expansion (2010-2013), 2014 expansion (January 2014), late expansion (after January 2014), or no expansion. Analysis showed that in nonexpansion states, lower proportions of non-Hispanic black patients underwent reconstruction compared with non-Hispanic white patients in all years, with the smallest disparity (–6.4%) in 2017. Decreases in differences in reconstruction rates between non-Hispanic black patients and non-Hispanic white patients were seen with the smallest disparities observed in 2014 (–2.5%) in early expansion states, in 2017 (–0.7%) in states that expanded in January 2014, and in 2017 (–4.5%) in late expansion states.

Convergence of reconstruction rates between non-Hispanic black women and non-Hispanic white women was also evident for the lower 2 quartiles of income levels. Disparities in reconstruction rates improved over time in states that expanded in January 2014, and parity was achieved in 2013 (+0.2%) for early expansion states and in 2015 (+0.8%) for late expansion states. Comparing women in the 2 lowest education levels, nonexpansion states had disparities exceeding 5% in all years. Differences in reconstruction rates improved in the states that expanded in 2010-2013 and January 2014 and diverged over time in the states that expanded after January 2014. No convergence in reconstruction rates was noted among the 2 highest income and education categories. In addition, while convergence of reconstruction utilization for the lowest education and income groups similarly coincided with Medicaid expansion, such convergence was not observed in nonexpansion states.

Sharon Lum, MD, Chair, Department of Surgery, Loma Linda University School of Medicine, and Medical Director, Loma Linda University Breast Health Center, CA, and lead investigator of the study, said, “The continued lack of racial parity in states without expansion suggests that a reduction in Medicaid access will negatively impact the gains achieved and should raise caution in today’s shifting sociopolitical environment.”

“The study suggests that Medicaid expansion was highly effective in doing what it was supposed to do—breaking down barriers to care,” she added.

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