Delays in breast cancer diagnosis after a state policy limiting Medicaid enrollment

Abstract

There currently is great interest in understanding the benefits and harms associated with Medicaid expansions and contractions. The Patient Protection and Affordable Care Act expanded eligibility for Medicaid to individuals and families with incomes up to 138% of the federal poverty level (FPL), although the Supreme Court later made this Medicaid expansion voluntary (to date, 31 states and the District of Columbia have expanded their Medicaid programs). More recently, the American Health Care Act considered by Congress in early 2017 sought to limit Medicaid enrollment substantially. Currently, to the best of our knowledge, relatively few data are available regarding the health implications of federal and state policies that contract Medicaid benefits.In this issue of Cancer, Tarazi et al 1 investigated the effects of a state policy that substantially limited Medicaid enrollment on the timeliness of breast cancer diagnosis. In 2005, Tennessee, which previously had provided coverage to individuals with incomes up to 400% of the FPL, adopted reduced income threshold levels consistent with traditional Medicaid coverage, resulting in the abrupt disenrollment of approximately 170,000 low-income beneficiaries. 2 The authors used this natural experiment to conduct a difference-in-difference analysis that compared late-stage diagnosis (cancers detected at a regional or distant stage) before and after the Tennessee policy change for women living in low-income areas (who were more likely to be affected by the change) versus those living in high-income areas. They observed a statistically significant increase of 3.3 percentage points in the percentage of women diagnosed with late-stage cancers after the policy change among women living in low-income versus high-income areas.This finding of an increase in the diagnosis of late-stage breast cancer is supported by results from prior studies that demonstrated that Medicaid disenrollment leads to reduced access to a usual source of outpatient care and increases in emergency room visits. 3-5 Low-income women who lose Medicaid coverage are likely to remain uninsured; therefore, they will have limited access to screening mammograms and may not seek care promptly when they experience symptoms of breast cancer. 6 Some women in Tennessee who lost their Medicaid coverage were eligible for the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), which provides free mammograms to uninsured and underinsured women who have incomes <250% of the FPL. However, the NBCCEDP generally reaches a minority of eligible women, 7 and women with incomes >250% of the FPL who were no longer covered by Medicaid would not have been eligible for the NBCCEDP. Although only a subset of women who lost Medicaid coverage would have benefitted from the NBCCEDP, without this program, the rate of late-stage diagnoses among low-income women would likely have been higher.Avoiding delays in the diagnosis of breast cancer is of crucial importance because of the higher cancer mortality and increased fin...

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