Plastic Surgery Research Council

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The Affordable Care Act State-Specific Medicaid Expansion Effect on Insurance Coverage and Breast Reconstruction Rates: A Difference-in-Difference Model Quasi-Experimental Study
Yoshiko Toyoda, BA1, Eun Jeong Oh, MA2, Alexandra Lin, BA1, Codruta Chiuzan, PhD2, Christine H. Rohde, MD, MPH1.
1Division of Plastic and Reconstructive Surgery, Department of Surgery, NewYork-Presbyterian Hospital, New York, NY, USA, 2Department of Biostatistics, Columbia University, Mailman School of Public Health, New York, NY, USA.

Background: Breast reconstruction is part of the complete care of the breast cancer patient, but insurance coverage remains a barrier to reconstruction, especially among those of lower socioeconomic status. Under the Affordable Care Act, states were given the option to expand Medicaid with federal assistance. As a result, 32 states (including DC) opted to expand Medicaid eligibility while 19 did not. Previous quasi-experimental studies took advantage of this unique state-specific policy implementation and found increased insurance coverage in expansion compared to nonexpansion states in the short-term. With longer-term data now available, we sought to study the effect of Medicaid expansion on changes in insurance coverage as well as specifically examine changes in breast reconstruction rates in expansion and nonexpansion states.
Methods: Seven states which all expanded Medicaid eligibility in 2014 and six nonexpansion states were selected for comparative analysis. Based on public availability of data, the American Community Survey was queried for insurance coverage from 2011-2016, and the Health Care Utilization Project-State Inpatient Data for reconstruction rates from 2011-2014. Difference-in-difference linear mixed model compared insurance coverage between expansion and nonexpansion states before and after enactment. Breast reconstruction rates post-enactment were compared between expansion and nonexpansion states.
Results: The increase in insurance rate in all persons covered by some type of health insurance from 2011-2016 was statistically greater in expansion than nonexpansion states (Fig. 1, p=0.0014). The increase in Medicaid coverage after Medicaid expansion was also significant in expansion compared to nonexpansion states (Fig. 2, p<0.0001). The yearly median rate of implant-based reconstruction post-expansion in 2014 was 48.54% versus 42.00% in expansion and nonexpansion states, respectively.
Conclusion: Medicaid expansion states saw significantly greater improvement in total insurance and Medicaid coverage between 2011-2016 than nonexpansion states. Expansion states also saw higher rate of implant-based reconstructions post-enactment than nonexpansion states. While these findings are limited due to the few number of states, expansion of insurance eligibility for those of lower socioeconomic class may improve access to reconstructive care in the long-term. Our study may inform further policy on Medicaid expansion for breast cancer patients.
Figure 1. All persons covered by some type of health insurance in expansion states (blue) and nonexpansion states (red). There was a significant change in all persons covered by insurance after Medicaid expansion in expansion vs. nonexpansion states (p=0.0014).
Figure 2. All persons covered by Medicaid in expansion states (blue) and nonexpansion states (red). There was a significant change in all persons covered by Medicaid after Medicaid expansion in expansion vs. nonexpansion states (p<0.0001).


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