Did Medicaid Expansion Mitigate Disparities in Post-mastectomy Reconstruction Rates?

BACKGROUND: Patient and socioeconomic factors both contribute to disparities in post-mastectomy reconstruction (PMR) rates. We sought to explore PMR patterns across the US and to determine if PMR rates were associated with Medicaid expansion. METHODS: The NCDB was used to identify women who underwent PMR between 2004-2016. The data was stratified by race, state Medicaid expansion status, and region. A multivariate model was fit to determine the association between Medicaid expansion and receipt of PMR. RESULTS: In comparison to Caucasian women receiving PMR in Medicaid expansion states, African American (AA) women in Medicaid expansion states were less likely to receive PMR (OR .96 [.92-1.00] P < .001). Patients in the Northeast (NE) had better PMR rates vs any other region in the US, for both Caucasian and AA women (Caucasian NE ref, Caucasian-South .80 [.77-.83] vs AA NE 1.11 [1.04-1.19], AA-South (.60 [.58-.63], P < .001). Interestingly, AA patients residing in the NE had the highest receipt of PMR 1.11 (1.04-1.19), even higher than their Caucasian counterparts residing in the same region (ref). Rural AA women had the lowest rates of PMR vs rural Caucasian women (.40 [.28-.58] vs .79 [.73-.85], P < .001]. DISCUSSION: Racial disparities in PMR rates persisted despite Medicaid expansion. When stratified by region, however, AA patients in the NE had higher rates of PMR than AA women in other regions. The largest disparities were seen in AA women in the rural US. Breast cancer disparities continue to be a complex problem that was not entirely mitigated by improved insurance coverage.