Medicaid Expansion May Not Improve Minority Access to Cancer Surgery

Medicaid expansion did not address racial disparity among patients undergoing cancer surgery.

Results from a large study suggest that despite Medicaid expansion decreasing the uninsured rate, it did not remove racial disparities for access to cancer surgery. This shows that these patients may not be receiving the necessary complex cancer care.

In the study, published by the Journals of the American College of Surgeons, the investigators analyzed New York State’s Medicaid expansion, which came prior to the passage of the Affordable Care Act (ACA).

This expansion was shown to improve access to surgical care, but minorities receiving the surgery did not increase compared with Caucasians. The researchers said that these findings provide insight into what Medicaid expansion can accomplish, and where improvements need to be made.

"This study shows that New York's Medicaid expansion, one of the largest in U.S. history before the Affordable Care Act, improved access to cancer surgery for the previously uninsured,” said the study's lead investigator, Waddah B. Al-Refaie, MD, FACS. “However, it did not appear to preferentially benefit ethnic and racial minorities who are typically the most vulnerable of American poorest population.”

Although the number of minorities receiving surgery for cancer did not significantly increase compared with Caucasians, Medicaid expansion in New York was still successful since it reduced the uninsured, and provided access to surgical care, according to the study.

"There was a sharp decrease in the uninsured, but the proportion of the racial minority patients undergoing cancer surgery through Medicaid -- about 25%African-Americans and 13%Hispanic -- did not change," Dr Al-Refaie said.

Interestingly, the number of minorities who received cancer surgery compared with Caucasians was not observed to change before or after Medicaid expansion.

"We know that roughly 50%of individuals newly eligible under the New York State Medicaid expansion were minorities,” said researcher Thomas DeLeire, PhD. “Thus, we would have expected the expansion to lead to a reduction in disparities -- that is that both the raw numbers and the proportion of minority use for cancer surgery to have increased.”

The investigators are currently conducting additional studies to explain why the number of minorities receiving cancer surgery did not increase under Medicaid expansion. The researchers believe that it could be due to selective referral patterns, in which non-minority patients are preferred over minority patients, according to the study.

"From establishing need for cancer surgery to actually having the surgery involves many steps, and is a complicated process to unravel," Dr Al-Refaie said.

Included in the study were 67,685 adults who received cancer surgery reimbursed by Medicaid between 1997 and 2006. The number of surgeries reimbursed increased from 8.9% to 15.1% during this time, while the uninsured rate plummeted 21.3%, according to the study.

However, more than 76% of all cancer surgeries were reimbursed through private insurance plans, but the number of surgeries did not increase.

"To our knowledge, this study and its findings represent one of the first reports in surgery on the lack of effect on Medicaid expansion on the most vulnerable of low income populations," said senior author Nawar Shara, PhD.

Although the expansion period studied was pre-ACA, these findings may help lawmakers to decide how to make decisions about Medicaid expansion during the potential repeal of the health law.

"It will be years before this type of evaluation can be done for the ACA-related Medicaid expansion, and we believe these findings should help open a dialogue about what could be done to uncover and improve potential inadequacies of this policy change," Dr Al-Refaie concluded. "Empirical evidence from our study can inform policy decisions regarding the much-contended Medicaid expansion in ACA."