Association of Medicaid Expansion With Mortality Disparity by Race and Ethnicity Among Patients With De Novo Stage IV Breast Cancer

Author(s): Catalina Malinowski, MPH, CHES, CHW¹; Xiudong Lei, PhD¹; Hui Zhao, PhD¹; Sharon H. Giordano, MD, MPH^1,2; Mariana Chavez-MacGregor, MD, MSc^1,2

Source: JAMA Oncol. 2022;8(6):863-870. doi:10.1001/jamaoncol.2022.0159

Dr. Lucio Gordan's Thoughts

This is an excellent article demonstrating the stark changes in mortality pre- and post-Medicaid expansion. Further advocacy efforts are needed to enhance access to care, minimize negative social determinants of health. Maintaining the population at risk healthier, with access to guidelines-driven care should not be a matter of much debate, but an action point for our legislators.

ABSTRACT

IMPORTANCE

Patients who are uninsured and belong to racial and ethnic minority groups or have low socioeconomic status have suboptimal access to health care, likely affecting outcomes. The association of the Affordable Care Act’s Medicaid expansion with survival among patients with metastatic breast cancer is unknown.

OBJECTIVE

To examine the association between Medicaid expansion and mortality disparity among patients with de novo stage IV breast cancer.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional, population-based study of survival using Cox proportional hazards regression and difference-in-difference (DID) analysis of data from the National Cancer Database and patients diagnosed as having de novo stage IV breast cancer between January 1, 2010, and December 31, 2016, residing in states that underwent Medicaid expansion on January 1, 2014. The preexpansion period was January 1, 2010, to December 31, 2013; the postexpansion period was January 1, 2014, to December 31, 2016. Data were analyzed between September 4, 2020, and November 16, 2021.

EXPOSURES

Comparison of survival improvement between patients of racial and ethnic minority groups and White patients in the preexpansion and postexpansion periods. Because of small numbers in the specific racial and ethnic minority groups, these patients were combined into 1 category for comparisons.

MAIN OUTCOMES AND MEASURES

Overall survival (OS) and 2-year mortality rate.

RESULTS

Among 9322 patients included (mean [SD] age, 55 [7] years), 5077 were diagnosed in the preexpansion and 4245 in the postexpansion period. The racial and ethnic minority group comprised 2545 (27.3%), which included 500 (5.4%) Hispanic (any race), 1515 (16.3%) non-Hispanic Black, and 530 (5.7%) non-Hispanic other including 25 (0.3%) American Indian or Alaska Native, 357 (3.8%) Asian or Pacific Islander, and 148 (1.6%) unknown, and 6777 (72.7%) were in the White patient group. In the preexpansion period, White patients had increased OS compared with patients of racial and ethnic minority groups (adjusted hazard ratio [aHR], 1.22; 95% CI, 1.10-1.35); this difference was not observed in the postexpansion period (aHR, 0.96; 95% CI, 0.86-1.08). A reduction in 2-year mortality was observed between the preexpansion and postexpansion periods (32.2% vs 26.0%). The adjusted 2-year mortality decreased from 40.6% to 36.3% among White patients and from 45.6% to 35.8% among patients of racial and ethnic minority groups (adjusted DID, −5.5%; 95% CI, −9.5 to −1.6; P = .006). Among patients in the lowest income quartile (n = 1510), patients of racial and ethnic minority groups had an increased risk of death in the preexpansion period (aHR, 1.28; 95% CI, 1.01-1.61) but lower risk in the postexpansion period (aHR, 0.75; 95% CI, 0.59-0.95). In this subset of patients, those of racial and ethnic minority groups had a greater reduction in 2-year mortality compared with White patients (adjusted DID, −12.8%; 95% CI, −22.2 to −3.5; P = .007).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, survival differences observed between patients of racial and ethnic minority groups and White patients in the preexpansion period were no longer present in the postexpansion period. A greater reduction in 2-year mortality was observed among patients of racial and ethnic minority groups compared with White patients. These results suggest that policies aimed at improving equity and increasing access to health care may reduce racial and ethnic disparities in breast cancer outcomes.

Author Affiliations

¹Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston ²Breast Medical Oncology Department, The University of Texas MD Anderson Cancer Center, Houston

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