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Did Expanding Medicaid Reduce Differences in Breast Cancer Death Rates Between Black and White Women?

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Expanded Medicaid coverage through the Affordable Care Act didn’t seem to reduce the disparity in breast cancer death rates between Black and white women, according to a study.

The research was published online on July 28, 2020, by the journal JCO Global Oncology. Read the abstract of “Evaluating the Effect of Medicaid Expansion on Black/White Breast Cancer Mortality Disparities: A Difference-in-Difference Analysis.”

About Medicaid expansion and the Affordable Care Act

Passed in 2010, the Affordable Care Act had a goal to dramatically reduce the number of people with no insurance. One requirement of the act was that nearly all Americans had to have health insurance.

Medicaid is the United States’ health insurance program for people with low income. Medicaid is administered by individual states. The Affordable Care Act expanded Medicaid coverage to people who make 138% of the federal poverty level ($17,236 per year in 2019). The June 2012 U.S. Supreme Court decision in the case challenging the constitutionality of the Affordable Care Act made the Medicaid expansion part of the act optional for states. States could start expanding Medicaid in 2014.

As of Feb. 19, 2020, 37 states and Washington, DC, have expanded Medicaid.

In practice, expanding Medicaid means that more people in that state will be eligible for low-cost health insurance.

About the study

From 1989 to 2017, the breast cancer death rate declined 40%. Researchers have shown that better treatments and earlier detection are two of the main reasons behind this decline.

Still, not all women have benefited from these improvements. Black women and white women are diagnosed with breast cancer at about the same rate. Yet, Black women die from breast cancer at a higher rate. Researchers have been trying to figure out why this is happening. Some possible reasons include:

  • Black women are often diagnosed with more advanced-stage disease than white women.
  • Breast cancer often has more aggressive characteristics in Black women.
  • Black women may have less access to high-quality prevention, early detection, and treatment.
  • Black women have higher rates of obesity and other health conditions that increase the risk of breast cancer, as well as the risk of having worse breast cancer outcomes.

Many experts think that a lack of access to care is a big part of the reason that Black women die more often from breast cancer than white women. Because expanding Medicaid meant that more people would have access to healthcare, the researchers who did this study wanted to see if it affected the difference in breast cancer death rates between Black and white women.

To do the study, the researchers looked at the number of people who died from breast cancer by state. The researchers did two analyses.

In the first analysis, they looked at the number of people who died from breast cancer in 2012-2013 (before Medicaid expansion) and the number who died in 2015-2016 (after Medicaid expansion) in all states that expanded Medicaid compared to states that didn’t expand Medicaid.

In the second analysis, the researchers looked at the same years of breast cancer death rates, but compared data from all states that expanded Medicaid to data from states that voted to expand Medicaid, but had not expanded it by January 2014.

The researchers found that expanding Medicaid did not change the difference in breast cancer death rates between Black and white women.

“Whereas the overall disparity in breast cancer mortality has historically been attributed to a variety of genetic, behavioral, and social factors, the breast cancer disparity between young Black and White women has proven to be driven by systemic social and epigenetic differences,” the researchers wrote. “Given the persistent structural racism and the evidence that these epigenetic differences influence tumor biology, it would be naïve to assume that Medicaid expansion would completely eliminate cancer disparities. Still, 3 years after a major health policy that drastically increased access to care, at minimum we expected to observe a significant trend toward greater equity.

“This study suggests, however, that Medicaid expansion may not have addressed the breast cancer mortality gap between Black and White women,” they continued. “The two leading explanations for this result center on assumptions of unequal access and quality: a lower proportion of African American women enrolled in Medicaid after expansion than did White women, and even though African American women were given access to free health insurance, the quality of the care available to this group was poor relative to the care available to White women. However, the purpose of this discussion is to dispute the two previous assumptions and introduce a third likely explanation — that the arrival of new Medicaid patients overloaded the capacity of health care providers, which disproportionately impeded breast cancer care for African American women in an already constrained, low-resource health system.”

What this means for you

The results of this study are very troubling. Expanding Medicaid was designed to improve health equity and help make sure that all people — no matter their race, age, ethnicity, economic status, or gender — had access to affordable, high-quality healthcare.

All women deserve the best breast healthcare possible. Differences in care that affect outcomes, such as screening, access to care, and quality and consistency of care, should be eliminated.

Screening is a good place to start. Most doctors agree that breast cancer that is diagnosed early is typically easier to treat and offers the best survival chances. Regular screening for breast cancer, including annual mammograms and breast exams by a medical professional, is important for everyone. Paying for healthcare can be difficult, especially if you have a limited income and no or inadequate health insurance or are covered only by Medicaid in a state that has not expanded Medicaid. But if you're older than 40, skipping regular mammograms is not an option. Stick with the screening plan you and your doctor decide is best for you. If scheduling problems or cost concerns are stopping you from getting a mammogram, talk to your doctor, a hospital social worker, or a staff member at a mammogram center. Ask about free mammogram programs and healthcare services in your area. It's your health and your future, and you deserve the best care possible.

Written by: Jamie DePolo, senior editor


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