NY State Medicaid expansion widened racial gap in access to high-quality cancer surgery

October 5, 2017, Georgetown University Medical Center

The 2001 New York State Medicaid expansion—what is considered a precursor to the Affordable Care (ACA)—widened the racial disparity gap when it came to access to high-quality hospitals for cancer surgery, according to a new study from Georgetown University.

The finding surprised the researchers who expected to see a shrinking racial gap, but instead found the proportion of minority Medicaid treated at hospitals that provide high-quality cancer surgery fell significantly compared to their white counterparts.

The New York State Medicaid expansion was the largest in U.S. history before passage of the ACA, which has increased Medicaid enrollment in 32 states as well as the District of Columbia.

The Journal of the American College of Surgeons (JACS) study included 67,685 patients, of which 15 percent were Medicaid beneficiaries or uninsured. Only 12 percent of the Medicaid beneficiaries were African-American and 67 percent were non-Hispanic white.

The researchers conclude that over a 21-month period following the state's Medicaid expansion, racial disparity increased by 18 percentage points in hospitals with the highest volume of cancer surgeries performed—an indicator of quality of surgical cancer care. Racial disparity in access to low-mortality hospitals—another quality measure—showed a similar pattern, increasing by 10 percentage points.

These disparities did not occur because of Medicaid insurance status. Researchers found access to Medicaid patients had increased at these hospitals. The researchers say the reason appears to be because, relative to the expansion, more white Medicaid patients and fewer African-American patients, received cancer surgery at high volume hospitals.

"Low-income non-Hispanic white patients may have been better able to obtain, or take advantage of the benefits of Medicaid for complex surgery," says the study's senior investigator, Waddah B. Al-Refaie, MD, FACS, Georgetown Lombardi Comprehensive Cancer Center Surgeon-In-Chief, and chief of surgical oncology at MedStar Georgetown University Hospital.

"We were very surprised by these unexpected findings," he says.

Al-Refaie adds that this disparity phenomenon may be playing out via the ACA's Medicaid expansion, but this potential issue has not yet been studied.

Al-Refaie says the study focused on measuring and quantifying this issue. As such, reasons behind these widened disparities are still needed. Al-Refaie speculates these aggravated trends could be due to multiple factors including factors (regionalization of specialty care that crowds out some African-American Medicaid patients), physician factors (referral patterns) or patient factors (desire to be treated at more local hospitals rather than regional centers).

This study follows Al-Refaie's finding in January 2017 that New York's Medicaid expansion improved access to for the previously uninsured, but did not preferentially benefit ethnic and racial minorities who are typically the most vulnerable of America's poorest populations. That study was also published in JACS.

"Compelling findings such as these reveal health inequities and drive us to advocate for equitable health policies," says the study's first author, David Xiao, a health justice scholar at Georgetown's School of Medicine.

Explore further: Large pre-ACA Medicaid expansion did not level health disparities in cancer surgery

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