ASO Author Reflections: Medicaid Expansion is Key in Mitigating Surgical Disparities in Low-Income Breast Cancer Patients.

Past

Low-income breast cancer patients face significant barriers in accessing oncologic surgical care. Consequently, they are less likely to receive guideline-concordant locoregional management—breast conservation therapy[1] or breast reconstruction after mastectomy.[2] The reasons for these surgical disparities are a complex interplay between access to care, patient, provider, and institutional-level factors. Emerging literature suggests Medicaid expansion might provide an avenue to address income-based differences in breast cancer diagnosis, treatment, and mortality. Specifically, breast cancer patients living in expansion states are presenting with earlier stages of disease[3] and experiencing increased utilization of breast reconstruction.[4] These results are significant, as the long-term implications of earlier stages of presentation and reconstruction use include improved survival, body image, and quality of life.[4] Nevertheless, due to the relatively recent implementation of Medicaid expansion, long-term studies are needed to better understand its implications for low-income patients across the cancer continuum.

Present

In their evaluation of pre- and post-expansion Medicaid eligible (ages 30–64 years) breast cancer patients in Ohio, Obeng-Gyasi et al. found that the effects of Medicaid expansion on narrowing income-based surgical disparities were mixed. For instance, study results suggest a reduction in the disparities between Medicaid/uninsured patients and their privately insured counterparts in the utilization of breast-conservation therapy (breast-conservation surgery + radiation) and breast reconstruction.[5] These results highlight a positive effect of expansion in reducing income-based disparities in oncologic surgery and receipt of guideline-concordant care. However, it should be noted that although surgical disparities were attenuated, they were not eliminated altogether. Moreover, Medicaid expansion did not appear to improve delays in time to surgical management, regardless of insurance type.[5]

Future

Medicaid expansion appears to be improving access to oncologic surgical and guideline concordant care among low-income breast cancer patients. However, the results from the study by Obeng-Gyasi et al. indicate there is still room for improvement, as income-based surgical disparities were narrowed but continue to persist. In addition, delays in time to surgery across insurance groups warrant close attention as this may have implications for long-term outcomes such as survival. As state legislators, federal lawmakers, and other healthcare stakeholders continue to debate the implementation and effectiveness of Medicaid expansion, the evolving literature on its impact on oncology patients should be considered. Moreover, within the context of the coronavirus pandemic, which has highlighted the detrimental consequences of poor access to care, policies such as Medicaid expansion are imperative to improving access to oncologic care.