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Medicaid rollback could increase late-stage breast cancer diagnoses

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June 26, 2017

A substantial reduction of Medicaid coverage for adult residents in Tennessee appeared linked to an increase in the diagnosis of late-stage breast cancer, according to research data published in Cancer.

“Women in Tennessee who were diagnosed with breast cancer were more likely to be diagnosed with late-stage disease after a substantial rollback of Medicaid coverage for adults in the state,” Wafa W. Tarazi, PhD, department of health behavior and policy at Virginia Commonwealth University, told HemOnc Today.

Wafa W. Tarazi

“We show that when a large population in a state loses Medicaid coverage, low-income women are more likely to be diagnosed with breast cancer at later stages, suggesting they did not receive screening or other primary care that may have facilitated earlier diagnosis. Our findings are important for policy makers who are considering changes to the Medicaid program.”

Facing financial difficulties, Tennessee’s Medicaid program terminated coverage in 2005 for nearly 170,000 nonelderly adults who failed to meet traditional requirements for coverage, leaving approximately 4% of the state’s nonelderly adults uninsured.

Previous studies have suggested that health insurance coverage is associated with earlier diagnosis and improved health outcomes among women diagnosed with breast cancer. Researchers used Tennessee Cancer Registry data from 2002 to 2008 to compare women diagnosed with breast cancer before and after the 2005 Medicaid disenrollment who lived in low-income zip codes (median income $38,700 in 2005) — who were more likely to be subject to Medicaid disenrollment — with a similar group of women who lived in high-income zip codes (median income > $38,700).

Changes in disease stage at the time of diagnosis and delays in treatment of more than 60 days and more than 90 days served as primary outcomes.

The majority of women in the study were white, married and insured (median age, 51 years).

The percentage of women diagnosed with late-stage disease increased in the period after disenrollment — from 35.4% to 40.2% in low-income zip codes and from 34.6% to 36.2% in high-income zip codes.

A significantly higher percentage of women living in low-income zip codes before disenrollment had delays of longer than 60 days to surgery (difference, 1.8; P < .001) and treatment (difference, 0.9; P = .03).

Researchers found an association between Tennessee’s Medicaid disenrollment and a 3.3-percentage point increase in late-stage diagnosis of breast cancer in women living in low-income zip codes compared with high-income zip codes (P = .024). That represented a 12.7% increase in the probability of a late-stage diagnosis after compared with before the disenrollment.

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The state’s disenrollment also appeared associated with a 1.9-percentage point decrease in having a delay of more than 60 days to surgery (P = .02) and a 1.4-percentage point decrease in having a delay of more than 90 days to treatment (P = .05) for women in low-income vs. high-income zip codes.

Additionally, before Tennessee’s Medicaid disenrollment, about 20% of women in low-income and high-income zip codes reported at least one comorbidity. After the policy change, about 36% reported having one or more comorbidities.

“Although the National Breast and Cervical Cancer Early Detection Program in Tennessee provided free mammograms to uninsured and underinsured women who had income below 250% of the federal poverty level, the program, like similar programs across the country, could only reach on average approximately 20% of eligible women,” researchers wrote. “Hence, many uninsured women were unable to receive regular mammograms.”

Researchers noted that although their findings may not be generalizable to other states, they could have important public health and policy implications for states considering rollbacks of Medicaid expansions implemented under the 2010 Patient Protection and Affordable Care Act.

Lindsay M. Sabik

“My concern is that reductions in health insurance coverage will likely limit access to primary care and preventive services that facilitate early diagnosis of breast cancer, putting affected low-income women at risk for poor health outcomes,” Lindsay M. Sabik, PhD, associate professor of health policy and management at University of Pittsburgh, told HemOnc Today. “Other states may see similar declines in health outcomes if they terminate Medicaid coverage for a large population of adults.”

Medicaid payments for breast cancer treatment in the year after diagnosis are estimated to be $19,209 for local, $38,230 for regional, and $63,253 for distant stage cancer, Sujha Subramanian, PhD, fellow of cancer economics and policy at RTI International, and Nancy Keating, MD, MPH, professor of health care policy and medicine at Harvard Medical School and physician at Brigham and Women’s Hospital, wrote in an accompanying editorial.

According to Subramanian and Keating, it is likely that federal and state policymakers will continue to consider rollbacks of Medicaid to address fiscal shortfalls. It also is important for those policymakers to understand that short-term policies have long-term consequences for the health of the low-income population, for whom Medicaid often is the only health insurance coverage option, they wrote.

“The study by Tarazi [and colleagues] provides additional insights regarding the negative consequences of Medicaid rollbacks for women at risk [for] or diagnosed with breast cancer,” they wrote. “Additional research, particularly research that uses patient-level data, will be useful for understanding consequences for individuals at risk [for] developing other cancers.” – by Chuck Gormley

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For more information:

Lindsay M. Sabik, PhD, can be reached at A613 Crabtree Hall, 130 De Soto St., Pittsburgh, PA 15261; email: lsabik@pitt.edu.

Wafa W. Tarazi , PhD, can be reached at Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, 830 East Main St., P.O. Box 980430, Richmond, VA 23298; email: taraziw@vcu.edu.

Disclosure: The Susan G. Komen Breast Cancer Foundation and Masey Cancer Center funded this study. The researchers and editorial authors report no relevant financial disclosures.