Impact of Medicaid disenrollment in Tennessee on breast cancer stage at diagnosis and treatment

Tarazi, Wafa W.; Bear, Harry D.; Harless, David W.; Sabik, Lindsay M.

doi:10.1002/cncr.30771

Cited by 27 publications

(21 citation statements)

References 19 publications

(34 reference statements)

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“…Our present study confirms delays to surgery and radiotherapy, but no delays between surgery and chemotherapy 6 . This is in contrast to the effect of the 2005 Medicaid disenrollment in Tennessee, which resulted in the later stage of disease at diagnosis of breast cancer and decreased delays to treatment 12 . As studies continue to evaluate the complex interactions between healthcare reform and cancer care, 13 we have attempted to understand other factors related to treatment delays.…”

Section: Discussionsupporting

confidence: 79%

Identifying factors influencing delays in breast cancer treatment in Kentucky following the 2014 Medicaid expansion

Bhutiani

Hicks

Huang

et al. 2020

Journal of Surgical Oncology

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Background and Objectives: A previous analysis of breast cancer care after the 2014 Medicaid expansion in Kentucky demonstrated delays in treatment despite a 12% increase in insurance coverage. This study sought to identify factors associated with treatment delays to better focus efforts for improved breast cancer care.Methods: The Kentucky Cancer Registry was queried for adult women diagnosed with invasive breast cancer between 2010 and 2016 who underwent up-front surgery. Demographic, tumor, and treatment characteristics were assessed to identify factors independently associated with treatment delays.Results: Among 6225 patients, treatment after Medicaid expansion (odds ratio [OR] = 2.18, 95% confidence interval [CI] = 1.874-2.535, P < .001), urban residence (OR = 1.362, 95% CI = 1.163-1.594, P < .001), treatment at an academic center (OR = 1.988, 95% CI = 1.610-2.455, P < .001), and breast reconstruction (OR = 3.748, 95% CI = 2.780-5.053, P < .001) were associated with delay from diagnosis to surgery. Delay in postoperative chemotherapy was associated with older age (OR = 1.155,95% CI = 1.002-1.332, P = .0469), low education level (OR = 1.324, 95% CI = 1.164-1.506, P < .001), hormone receptor positivity (OR = 1.375, 95% CI = 1.187-1.593, P < .001), and mastectomy (OR = 1.312, 95% CI = 1.138-1.513, P < .001). Delay in postoperative radiation was associated with younger age (OR = 1.376, 95% CI = 1.370-1.382, P < .001), urban residence (OR = 1.741, 95% CI = 1.732-1.751, P < .001), treatment after Medicaid expansion (OR = 2.007, 95% CI = 1.994-2.021, P < .001), early stage disease (OR = 5.661, 95% CI = 5.640-5.682, P < .001), and mastectomy (OR = 1.884, 95% CI = 1.870-1.898, P < .001).Conclusions: Patient, tumor, and socioeconomic factors influence the timing of breast cancer treatment. Improving timeliness of treatment will likely require improvements in outreach, education, and healthcare infrastructure.

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Section: Discussionsupporting

confidence: 79%

Identifying factors influencing delays in breast cancer treatment in Kentucky following the 2014 Medicaid expansion

Bhutiani

Hicks

Huang

et al. 2020

Journal of Surgical Oncology

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“…Tennessee in the mid–2000 s had the largest contraction of its Medicaid program in its history due to budgetary challenges [10,11]. A new paper published on breast cancer outcomes in Tennessee post Medicaid contraction indicates that post contraction of the Tennessee Medicaid program, there were increases in delays in accessing treatment and an increase in later stage of diagnosis for breast cancer [12]. Further study is needed to examine how closely the regional variations in disparity correlate with variations in provision of health insurance.…”

Section: Discussionmentioning

confidence: 99%

Disparity in breast cancer mortality by age and geography in 10 racially diverse US cities

Sighoko

Hunt

Irizarry

et al. 2018

Cancer Epidemiology

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While the mortality rate for breast cancer is lower among younger women, the NHB:NHW disparities, as measured by rate ratios, are most pronounced in these age groups. Given the absence of available data regarding incidence, stage and subtypes, further research is necessary and such research is important, given the possible policy implications of these results with respect to screening guidelines and coverage for mammography and breast cancer treatment in particular for younger NHB women.

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“…In this issue of Cancer , Tarazi et al 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 .…”

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confidence: 99%

“…Surprisingly, Tarazi et al found that Tennessee's Medicaid disenrollment resulted in a statistically significant lower rate (1.9 percentage points) of surgical delays of >60 days for women living in low‐income areas compared with women living in high‐income areas . Women in both income groups experienced more surgical delays after the policy change, but the increase was greater for women in high‐income areas.…”

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confidence: 99%

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

Subramanian

Keating

2017

Cancer

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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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Impact of Medicaid disenrollment in Tennessee on breast cancer stage at diagnosis and treatment

Cited by 27 publications

References 19 publications

Identifying factors influencing delays in breast cancer treatment in Kentucky following the 2014 Medicaid expansion

Identifying factors influencing delays in breast cancer treatment in Kentucky following the 2014 Medicaid expansion

Disparity in breast cancer mortality by age and geography in 10 racially diverse US cities

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

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