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Affordable Care Act State-specific Medicaid Expansion Is Correlated With Increased Rates Of Implant-based Breast Reconstruction Compared To Autologous Reconstruction
Ishani D. Premaratne, BA1, Yoshiko Toyoda, MD1, Eun Jeong Oh, MA2, Codruta Chiuzan, PhD2, Christine H. Rohde, MD, MPH1.
1NewYork-Presbyterian Hospital, New York, NY, USA, 2Columbia University Mailman School of Public Health, New York, NY, USA.

PURPOSE: Breast reconstruction for the breast cancer patient has been shown to provide substantial benefits. However, disparities in access to breast reconstruction remain due to socioeconomic factors and access to health insurance. Under the Affordable Care Act, states were given the option to expand Medicaid. Thirty-two states (including DC) opted to expand Medicaid eligibility in 2014 while 19 did not. The unique, state-specific outcome of the Supreme Court ruling on Medicaid expansion provides an opportunity to study its effects by juxtaposing expansion states with non-expansion states. Our groupís prior studies have quantified the effect of Medicaid expansion on changes in insurance coverage and breast reconstruction rates in expansion and non-expansion states from 2011-2016. Given the existing health disparities especially among breast cancer patients, and the significant benefits of breast reconstruction, we now aim to study rates of autologous vs. implant-based reconstruction in Medicaid expansion states compared to non-expansion states using available data from 2010 to 2014.
METHODS: Seven states which all expanded Medicaid eligibility in 2014 and five non-expansion states were selected for comparative analysis. Health Care Utilization Project‑State Inpatient Data was queried for reconstruction rates from 2010‑2014. In order to study trends in reconstruction rates over time, subgroup analysis was conducted to assess rates of implant vs. autologous reconstructions.
RESULTS: Overall, the rate of implant-based reconstruction was higher in expansion states vs. non-expansion states for every year studied. The increase in implant-based reconstructions from 2010-2014 was also greater in expansion (11.86% increase) vs. non-expansion states (1.96% increase, p < 0.05) (Figure 1A). The yearly median rate of implant‑based reconstruction post‑expansion in 2014 was 48.54% versus 42.00% in expansion and non-expansion states, respectively. In comparison, the overall rate of autologous reconstruction was higher in non-expansion states for every year studied, though the percent of autologous reconstructions increased in both expansion states (13.52% increase) and non-expansion states (10.75% increase) from 2010 to 2014 (Figure 1B).
CONCLUSIONS: Medicaid expansion states saw a significant increase in implant-based reconstruction compared to non-expansion states from 2010 to 2014. These data add to our groupís prior findings that increased access to health insurance also led to an increase in mastectomy rate without a significant increase in number of available reconstructive surgeons or operating room time. This illuminates the downstream effects of this sweeping national health care policy, which improved access to reconstructive care, but has also led to a disproportionate increase in implant-based reconstructions which take much less time than autologous breast reconstructions. This study suggests that increased access to and thus demand for health care services, while supply of providers remains the same, may in fact lead to an unexpected preference for certain reconstructive options over others. As evidenced by these findings, national health care policy may have unforeseen effects on the reconstructive options offered to and ultimately chosen by patients.


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