Medicaid Cuts Delay Breast Cancer Diagnosis

Megan Brooks

June 27, 2017

Women in Tennessee who were diagnosed with breast cancer were more likely to be diagnosed with late-stage disease following state cuts in Medicaid coverage in 2005, according to a new analysis.

"We show that a reduction in Medicaid coverage is associated with increases in late-stage diagnosis of breast cancer, which is more costly to treat and is associated with a greater risk of death relative to early-stage diagnosis," coauthor Lindsay Sabik, PhD, of the University of Pittsburgh Graduate School of Public Health in Pennsylvania, told Medscape Medical News.

"Medicaid rollbacks may limit access to preventive and primary care that facilitates early diagnosis for low-income patients," she added.

The Affordable Care Act expanded Medicaid eligibility, although the US Supreme Court later left it up to states to decide whether or not to expand Medicaid coverage. Tennessee did, but in 2005, faced with financial difficulties, the state rolled back Medicaid coverage for nonelderly adults who failed to meet traditional requirements for Medicaid coverage. As a result, nearly 170,000 women, or roughly 4% of the state's nonelderly population, lost Medicaid coverage.

Dr Sabik and colleagues assessed the effects of the 2005 Medicaid disenrollment in Tennessee on breast cancer stage at diagnosis and delays in treatment for women living in low-income vs high-income ZIP code areas in the state. Low-income ZIP code areas were defined as those in which the median income was $38,700 or less in 2005, which was equivalent to 200% of the federal poverty level for a family of four.

Overall, women in Tennessee were diagnosed with breast cancer at later stages and experienced more delays in treatment after the Medicaid rollback, the investigators found.

In low-income areas, where more residents had Medicaid insurance, the percentage of breast cancer cases diagnosed at a late stage of disease (regional or distant stage) jumped from 35.4% in 2002-2004, before the Medicaid cuts, to 40.2% in 2006-2008, after the cuts. In high-income areas, the percentage of cases diagnosed at a late stage went from 34.6% before the 2005 Medicaid cuts to 36.2% afterward.

There was a 3.3 percentage point increase in cases of late-stage disease for women living in low-income ZIP code areas relative to women living in high-income ZIP code areas, the authors report.

For women living in both low- and high-income areas, the rates of delays in surgery and treatment after the Medicaid cuts were higher. For women living in low-income areas, the rate for a delay in surgery of more than 60 days increased significantly, from 12% in the period before the cuts to 14.3% afterward (P = .005). For patients living in high-income ZIP code areas, the rate for a delay of >60 days in surgery increased from 10.2% before the cuts to 14.4% afterward (P < .001).

Shortsighted Policies

This study provides evidence of the "potential negative health impacts of Medicaid contractions" on breast cancer, the authors say.

"While we did not look at other cancers and can't know whether the effect would be the same, there is reason to expect that we may see similar or more dramatic patterns for other cancers," first author Wafa Tarazi, PhD, of Virginia Commonwealth University School of Medicine in Richmond, told Medscape Medical News.

"Low-income uninsured women can get free mammograms and Pap tests through the National Breast and Cervical Cancer Early Detection Program, so for cancers without similar programs available, uninsured patients may have an even more difficult time accessing care necessary for a timely diagnosis," she noted.

The study was published online June 26 in Cancer.

In an accompanying editorial, Sujha Subramanian, PhD, of RTI International, Waltham, Massachusetts, and Nancy Keating, MD, MPH, of Brigham and Women's Hospital and Harvard University in Boston, say it is important that policy makers "understand that such short-term policies have longer-term consequences for the health of the low-income population, for whom Medicaid is often the only health insurance coverage option."

Loss of Medicaid coverage has a "detrimental impact on low income breast cancer patients. Sujha Subramanian

Yet "relatively few data are available regarding the health implications of federal and state policies that contract Medicaid benefits," they write.

This study shows that loss of Medicaid coverage has a "detrimental impact on low-income breast cancer patients," Dr Subramanian commented to Medscape Medical News.

"With Medicaid coverage, breast cancers are identified at an earlier stage, when treatments are more effective and healthcare costs of providing the treatments are lower. Affordability is a huge issue, and even when low-income uninsured women realize they are experiencing potential breast cancer symptoms, they are likely to delay seeking care, as they may not have the funds available to pay for physician visits and diagnostic procedures," added Dr Subramanian.

The study had no commercial funding. The authors and editorialists have disclosed no relevant financial relationships.

Cancer. Published online June 26, 2017. Abstract, Editorial

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