Medicaid expansion under the Affordable Care Act was associated with significant increases in breast reconstruction among non-Hispanic Black women, achieving parity at times with non-Hispanic White women, according to a new study presented by Sharon Lum, MD, and colleagues at the American Society of Breast Surgeons (ASBrS) Annual Meeting. The study also found a significant growth in reconstruction rates among women with lower income and education levels during the same time period (Abstract 139).
“In the past, it has been well reported that the rate of breast reconstruction following mastectomy as well as interventions consistent with high quality care have been consistently lower among Black than White women,” said Dr. Lum, of Loma Linda University Health. “The timeline for broadening Medicaid qualification criteria, providing coverage to those who had previously been uninsured, corresponded directly with the timeline for mitigation of breast reconstruction disparities in race, income, and education.”
“Perhaps surprisingly, for any medical treatment, it is extremely rare that these timelines would coincide so closely in such a large-scale population,” added Dr. Lum. “The study suggests that Medicaid expansion was highly effective in doing what it was supposed to do—breaking down barriers to care."
The study suggests that Medicaid expansion was highly effective in doing what it was supposed to do—breaking down barriers to care.— Sharon Lum, MD
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Study Details and Findings
The study examined 1,196,859 patients age 40 and older in the National Cancer Database who underwent mastectomy with or without reconstruction from 2010 to 2017. Overall, multivariable analysis found that patients who were younger, were non-Hispanic White, had higher income or education levels, had a lower comorbidity index, were insured, and had nonmetastatic disease were significantly more likely to have undergone reconstruction.
It also found increasing rates of breast reconstruction for non-Hispanic Black women, as well as for women in lower income and education levels closely following the timeline of Medicaid qualification criteria expansion. In states that did not implement expansion, lower proportions of non-Hispanic Black patients underwent reconstruction than non-Hispanic White patients throughout the time period examined.
Dr. Lum explained that although the official date for Medicaid expansion was January 2014, state timelines varied, and some states did not enact any qualification changes. In the study, states were categorized as early expansion (2010–2014), 2014 (January 2014) expansion, late expansion (after 2014), and no expansion. Difference in difference regression analyses with interaction terms were used to examine annual trends for utilization of breast reconstruction by racial/ethnic, income, and education status.
Beyond simply a rise in reconstruction, the study found the proportion of non-Hispanic Black patients undergoing the procedure exceeded non-Hispanic White patients in early-expansion states in 2014 (+0.21%), in 2014 expansion states in 2015 (+0.28%), and in late-expansion states in 2017 (+0.19%). In addition, a convergence of reconstruction utilization for lowest education and income groups similarly coincided with Medicaid expansion. Convergence was not seen in nonexpansion states.
“Sometimes a picture does speak a thousand words,” said Dr. Lum. “Our graphs comparing reconstruction rates among non-Hispanic Black and non-Hispanic White women reflected the timeline of Medicaid changes so closely that they suggest a strong causal relationship. 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.”
Disclosure: For full disclosures of the study authors, visit breastsurgeons.org.
