Medicaid expansion and breast reconstruction

A retrospective cross-sectional study has found that Medicaid expansion has increased the rates of autologous breast reconstruction in patients undergoing mastectomy.

However, the study in JAMA Network Open also concluded that Medicaid expansion resulted in lower rates of reconstruction among patients of color, including African American and Hispanic.

The study consisted of 51,340 patients from the State Inpatient Database between January 2012 and September 2015.

Patients were identified via the International Classification of Diseases, Ninth Revision, codes for breast cancer, mastectomy and autologous breast reconstruction.

Data from 3 states that expanded Medicaid (New Jersey, New York, and Washington) were compared to 3 states that did not expand Medicaid (Florida, North Carolina, and Wisconsin).

The Patient Protection and Affordable Care Act’s Medicaid expansion was implemented in 2014. The pre-expansion period for the study spanned 2 years (2012 and 2013), while the post-expansion period was 1.75 years (2014 through the third quarter of 2015).

Among the 45,850 patients who underwent mastectomy and the 9,215 patients who received autologous breast reconstruction, 67% were White and 59% had private insurance.

The use of immediate or delayed autologous reconstruction increased from 18.1% to 23.0% throughout the study period. Compared with 2012, the odds of reconstruction were 64% higher in 2015.

African American patients had a 43% higher likelihood of reconstruction compared with White patients, regardless of state of residence (P <.001), which roughly mirrored the 44% higher likelihood among Hispanic patients (P <.001).

Nonetheless, Medicaid expansion was associated with a 28% decrease in the odds of reconstruction in African American patients (P <.001); a 40% decrease in Hispanic patients (P <.001); and a 20% reduction in patients of Asian, Native American, or other minority race/ethnicity (P =.01).

But Medicaid expansion was not linked to changes in the odds of reconstruction for White patients.

“This study adds to the body of evidence of downstream implications of national health care policies and their ability to further existing racial/ethnic disparities in the use of autologous breast reconstruction,” wrote the authors.

The findings point to factors other than hospital costs and care outcomes that influence the decision for breast reconstruction, according to the authors.

Among the obstacles faced by patients seeking breast reconstruction are the direct expenses like high premiums and out-of-pocket payments, as well as the indirect expenses, such as time away from work and hospitalization.

“The time-intensive surgery and recovery process could substantially deter disadvantaged patients with limited resources,” wrote the authors.

The study’s results concur with previous studies that show that less than 20% of postmastectomy patients undergo autologous breast reconstruction, despite well-documented long-term advantages.

Such a low rate could be attributed to the lack of physician knowledge about psychosocial benefits and/or access barriers to a specialty center performing autologous breast reconstruction; also, deficiencies in the clinician-patient relationship can play a role.

The authors noted that people who are uninsured or underinsured are more likely to delay seeking care, thereby often presenting with late pathologies or more severe disease, which may influence a clinician’s discussion of breast reconstruction.

Two limitations of the study are that database analysis is dependent on the accuracy of the data captured and that the study is not generalizable to other forms of breast reconstruction like implant-based reconstructions.

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Reference

  1. Huynh KA, Jayaram M, Wang C, et al. Factors associated with state-specific Medicaid expansion and receipt of autologous breast reconstruction among patients undergoing mastectomy. JAMA Netw Open. 2021;4(8):e2119141. doi:10.1001/jamanetworkopen.2021.19141