Introduction
Over the past decade, states have tried a range of policy levers to improve breast cancer care: expanding screening mandates, boosting targeted public health spending, and addressing regional provider shortages. Theoretically, these efforts should improve access to care, as well as shift how these preventative and diagnostic efforts are reimbursed. However, the results tell a different story: none of these factors significantly influence what commercial payers actually pay providers.

Mandates Without Muscle
Our analysis found no statistically significant relationship between state screening mandates and reimbursement rates. Whether a state required more comprehensive coverage or not, commercial payers did not adjust payment levels in meaningful ways. In practice, insurers appear to take advantage of federal efforts exemplified by codified mandates: if they are legally required to cover a service, they often attach lower rates, knowing providers must still deliver care. This discrepancy counteracts the efforts put forth by public health, disincentivizing expanded access by leaving providers inadequately reimbursed to sustain preventive care programs.

Public Spending, Private Resistance
The same disconnect appeared when we looked at state spending allocated per capita for public health. Spending ranged from $0 to $423, with an average of $61 spent per resident. Though some states allocate far more public dollars per capita to health programs, reimbursement variation remains insignificant. Public health spending in practice covers a wide array of community needs, inclusive of vaccination campaigns, environmental health, maternal-child health programs, and substance use prevention. While some portions may indirectly support cancer prevention or screening outreach, the funds are rarely earmarked specifically for breast cancer. This means that even states with generous per-capita allocations may be channeling most of those dollars into other pressing priorities, diluting the impact on oncology care. Until insurance pay structures reward preventive cancer care, broader public health spending will remain disconnected from how providers are actually paid to deliver these services.

Provider Density Doesn’t Tip the Scale
Physician shortages continue to be a growing concern throughout the nation, yet disproportionately affect rural areas. Further, primary care physicians are facing exaggerated workforce pressures due to lower incomes, compared to their specialist peers. The widening income gap discourages medical students from pursuing primary care careers, reinforcing shortages and placing additional strain on existing providers. These dynamics perpetuate longstanding health disparities: communities with fewer providers often struggle with delayed diagnoses, limited screening opportunities, and poorer outcomes. However, when examining physicians related to breast cancer care specifically (oncologists, gynecologists, plastic surgeons), states with higher relevant specialists per capita did not see different reimbursement patterns. 

This finding highlights the double-edged sword of a capitalistic healthcare system. In rural areas with very few providers, reimbursement rates did not rise as one might expect in a near-monopoly market. In large metropolitan areas, where physicians are plentiful and costs of living are high, rates also did not climb. One would assume that either extreme could justify higher reimbursement, yet our analysis showed neither scarcity nor surplus had any effect. Reimbursement remained largely disconnected from provider supply, reinforcing that payer behavior is driven less by market dynamics and more by the burden of disease itself.

What Moves The Needle in Reimbursement
By contrast, population burden proved to be decisive. States with higher percentages of uninsured residents had significantly higher reimbursement, suggesting that payers may hedge against uncompensated care by raising rates in riskier markets. For providers, caring for uninsured patients often means delivering uncompensated care, and commercial payers appear to offset that risk by ascribing higher rates in these markets. Similarly, states with higher average Hierarchical Condition Category (HCC) risk scores, a marker of greater clinical burden, also aligned with higher reimbursement. Notably, this metric is known to be a factor in the calculation of federal medicare payments, but also, commercial payers seem to follow this trend. In the commercial market, our findings suggest that these risk profiles also influence contracted pay structures: the sicker the population, the higher the payment. Finally, by tying reimbursement to documented disease burden rather than outcomes or prevention, we solely reward complexity once it emerges, rather than encouraging interventions that could reduce future risk.‍

Trek Health and Pricing Transparency
At Trek Health, we identify reimbursement discrepancies. Our analytics turn CMS Transparency in Coverage data into insights that show providers where reimbursement is driven by burden, not by policy or prevention. As this data has been long hidden by commercial payers, Trek Health is the market leader in uncovering these staggering disparities in payment logic and equity. By surfacing rate differences, we help health systems recover lost revenue, negotiate smarter contracts, and advocate for fairer payment structures that better align with long-term patient outcomes. Not even legislation, public spending, or physician access create meaningful incentives in commercial payment structures; only population risk, recognized once it is nearly too late, drives pay rates. Trek Health equips providers to see beyond policy assumptions and use data to push for reimbursement models that drive both equity and better outcomes.

See here for data sources.