Medicaid expansion in Kentucky improves breast cancer care for women 20 to 64 years old
Since passage of the Affordable Care Act in 2010, 32 states and the District of Columbia have expanded Medicaid coverage, with the federal government picking up the tab for the increased costs. In Kentucky, one of the Medicaid expansion states, a University of Louisville study of breast cancer care has found a connection between Medicaid expansion and improved quality of breast cancer care, including an increase in diagnosis of early stage disease and greater utilization of breast-conserving surgery instead of more invasive operations such as mastectomy. However, study authors also reported less robust improvements in efficiency and timing of postsurgical therapy.
"What we learned is that the expansion of some form of third-party coverage for health care leads to people doing more things that are intrinsically good for their health," said senior study author Hiram C. Polk, Jr. MD, FACS, of the division of surgical oncology in the department of surgery named for him at the University of Louisville. The study, first presented at the Southern Surgical Association 129th annual meeting in December 2017, appears as an "article in press" on the website of the Journal of the American College of Surgeons in advance of print publication.
The publication is timely, as the Centers for Medicare and Medicaid Services has already permitted Kentucky to implement a work requirement for able-bodied individuals to receive Medicaid, and as Virginia, a state that has not yet expanded Medicaid, takes up expansion with a work requirement. The Kentucky waiver is already the subject of a court challenge to roll it back.
Dr. Polk explained the rationale for using breast cancer as a marker of the impact of Medicaid expansion. "Breast cancer and colon cancer are very common cancers," he said. "Our goal was to get an early measure of what really happened with Medicaid expansion." The study evaluated measures related to breast cancer from 2011 to 2016, using 2014, the year Kentucky's Medicaid expansion went into effect, as the cutoff between the pre- and post-Medicaid expansion periods. "We knowingly took on the onus of possibly making too early of an observation on Medicaid expansion, but the degree of change that occurred so promptly in two years surprised me," Dr. Polk said.
The study queried the Kentucky Cancer Registry for all women age 20 to 64 diagnosed with breast cancer between 2011 and 2016. From 2011 to 2013, 635,547 screening mammograms were performed in the state; that number increased to 680,418 from 2014 to 2016. In 2011 alone, 208,600 screening mammograms were performed vs. 234,315 in 2016. The number of screening mammograms covered by Medicaid increased from 5.6 percent before expansion to 14.7 percent after, and the number of women who had screening mammograms and were uninsured declined almost tenfold, from 0.53 percent before to 0.05 percent after expansion.
Dr. Polk, who served one year as Kentucky's public health commissioner under current Kentucky Gov. Matt Bevin, said of the sharp increase in mammography rates in Kentucky, "It bent the curve upward."
Breast cancer incidence and treatment rates did not vary significantly from year to year. However, the changes in the rates of early-stage vs. late-stage disease treated in the pre- and post-Medicaid expansion periods were statistically significant. Early stage (stage I-II) breast cancers accounted for 64.5 percent of the diagnoses in 2011-2013 vs. 66.7 percent in 2014-2016; late-stage (III-IV) cancers comprised 15 percent vs. 12.9 percent in the respective periods (p=0.002).
Rates for breast-conserving surgery increased significantly after Medicaid expansion—from 44 percent pre-expansion to 48.8 percent (p<0.001)—whereas rates of other resections, including mastectomy, declined—from 50.5 percent to 44.5 percent.
While time from diagnosis to surgical treatment for the disease was shorter before expansion—an average of 28.6 days vs. 36 (p<0.001)—two other key treatment variables were either unchanged or improved after expansion: time from the operation to chemotherapy (47.5 days before expansion and 46.6 days after, p=0.26); and time from the operation to radiation (96.4 days vs. 91.5, p<0.001).
The study noted that the findings mirrored those of other state experiences with either expansion or contraction of Medicaid programs, but Dr. Polk said that a thorough analysis of the Medicaid expansion in Kentucky requires a longer-term study. "This needs to be re-done in three more years so we have five years of follow-up," he explained.