Association of Medicaid Expansion with Reduction in Racial Disparities in the Timely Delivery of up-front Surgical Care for Patients with Early-Stage Breast Cancer.

Abstract

We evaluated the association between Medicaid expansion and time to surgery among patients with early-stage breast cancer (BC). Delays in surgery are associated to adverse outcomes. It is known that underrepresented minorities are more likely to experience treatment delays. Understanding the impact of Medicaid expansion on reducing racial and ethnic disparities in healthcare delivery is critical. This was a population-based study including women ages 40-64 with stage I-II BC who underwent upfront surgery identified in the National Cancer Database (2010-2017) residing in states that expanded Medicaid on January 1, 2014. Difference-in-difference (DID) analysis compared rates of delayed surgery (>90d from pathological diagnosis) according to time period (pre-expansion [2010-2013] and post-expansion [2014-2017]) and race/ethnicity (White vs. racial and ethnic minority), stratified by insurance type (private vs. Medicaid/uninsured). Secondary analyses included logistic and Cox proportional hazards regression. All analyses were conducted among a cohort of patients in the non-expansion states as a falsification analysis. Finally, a triple-differences approach compared pre-expansion with the post-expansion trend between expansion and non-expansion states. Among Medicaid expansion states, 104,569 patients were included (50,048 pre- and 54,521 post-expansion). In the Medicaid/uninsured subgroup, Medicaid expansion was associated with a -1.8% point (95% CI -3.5% to -0.1, P =0.04) reduction of racial disparity in delayed surgery. Cox regression models demonstrated similar findings (adjusted DID hazard ratio 1.12 [95% CI 1.05-1.21]). The falsification analysis showed significant racial disparity reduction among expansion states but not among non-expansion states, resulting in a triple-difference estimate of -2.5% points (95% CI -4.9% to -0.1%, P =0.04) in this subgroup. As continued efforts are being made to increase access to healthcare, our study demonstrates a positive association between Medicaid expansion and a reduction in the delivery of upfront surgical care, reducing racial disparities among patients with early-stage BC.