Medicaid Expansion Has A Positive Influence On Louisiana Women With Breast Cancer
Born and raised in New Orleans, I have always thought that Louisiana was a bit of a “banana republic.” My thoughts were re-enforced following passage of the Affordable Care Act (ACA) which included states ability to expand Medicaid. This occurred in the face of the fact that 6 of the top 10 most impoverished states are in the deep south, including Louisiana. Change unexpectedly arrived in November of 2015 with the election of John Bel Edwards as Governor. In his first official act, Governor Edwards elected to accept the federal government’ offer to expand Medicaid. This alone could not remove Louisiana from my banana republic list, but it was a beginning. Earlier this year, an article in a major peer-reviewed journal caught my attention. It compared the breast cancer stage and insurance coverage in women living in 45 expansion and non-expansion states. The researchers found that the expansion of Medicaid was associated with a reduced number of uninsured patients and a reduced number of advanced-stage breast cancer. Though Louisiana was included in this study it was unclear what was specifically happening in our state. Then in November 2020, in the journal Cancer (a very prestigious journal) a very detailed study was published from researchers from the Louisiana Cancer Research Center. This was a particularly important study in that Louisiana waited a full 2 years before Medicaid expansion allowing ample time and adequate patient numbers to allow a legitimate comparison on the outcome of women with breast cancer in Louisiana.
Prior to the implementation of the ACA in January 2014, 18% of the non-Medicare’s US population did not have health insurance. Louisiana ranks as the third poorest state in the nation with one of the lowest median incomes. Louisiana also ranks 28th in the nation in breast cancer incidence and yet second highest in mortality. In 2018 the Louisiana Research Consortium was formed by researchers primarily from Louisiana State University and Tulane University. The research was housed primarily in the Louisiana Cancer Research Center (see photo). Its mission was to analyze and publish data regarding cancer in Louisiana. The study in Cancer, was the first single state study to address the impact of Medicaid expansion on breast cancer outcomes.
After expansion, the percentage of women with stage I disease increased by 8%. At the same time, there was a 4.5% decrease in stage II and stage III breast cancer. This shift was noted for both White and African American women though more pronounced for African Americans. The ACA also resulted in a decrease in uninsured, non-Medicare women. Younger women had the largest decrease (4.3-fold) compared to older women (3-fold). In urban areas of Louisiana, the uninsured rate dropped from 6.3% to 2.3%. In rural areas of the state, a more dramatic drop in the uninsured rate occurred dropping from 8% to 0% following the implementation of ACA expansion!
The ACA was signed into law in 2010. Among other things “it expanded Medicaid eligibility to all adults in households earning up to 138% of the federal poverty level or approximately $34,638 for a family of 4 as of 2018.” Though the ACA originally decreed all states to implement Medicaid expansion, it was ruled unconstitutional by the Supreme Court. This gave each state the option of expanding or not expanding the ACA. Prior to grasping expansion, Louisiana had an uninsured rate of 42% for nonelderly, low income adults, one of the highest in the US. Since embracing Medicaid expansion, Louisiana’s uninsured rate has dropped to 8%, lower than the national average of 8.9%. To summarize, “the results of the current study demonstrated that ACA expansion dramatically increased the percentage of patients receiving Medicaid in Louisiana, decreased the number of uninsured individuals by nearly 50%, increased the percentage of patients diagnosed with early-stage disease by 27%, increased the percentage of patients receiving postoperative RT after BCS by 19%, and decreased the percentage of patients having delayed receipt of RT for early-stage disease by 16%”. By accepting expansion, Louisiana increased access to care in an historically underserved population. This resulted in a significant shift to an earlier stage of disease.