Abstract B076: Did the Affordable Care Act improve insurance coverage and stage at diagnosis among nonelderly underserved breast cancer patients?
Authors: Silva Abigail , Guzman Arielle , Picard Charlotte , Molina Yamile , Balanean Alexandrina , Khosla Paramjeet 
Published: August 2020

Abstract
Background: Through its various provisions, the Patient Protection and Affordable Care Act (ACA) has the potential to increase access to cancer care, particularly among the most vulnerable, and reduce disparities in cancer care and outcomes. The ACA might ameliorate disparities in cancer stage by improving access to health care coverage and preventative care, such as screening. The purpose of the present analysis is to examine the change in the percent uninsured and early-stage diagnosis among nonelderly breast cancer patients who receive care in an urban safety-net institution.
Methods: We conducted a retrospective, observational study using medical record and cancer registry data from an urban minority-serving hospital. Patients were identified through the cancer registry and included if they were non-Latina (nL) black, or Latina; diagnosed or treated with stage I-IV breast cancer between 2008-2016; and aged 18-64 years at diagnosis. The pre- and post-ACA periods of the expanded health care coverage provision were identified as 2008-2013 and 2014-2016, respectively. Descriptive statistics were calculated to compare patient demographic, insurance, health care use, and tumor characteristics between the pre- and post-ACA periods, overall and across racial/ethnic groups. Logistic regression models, with model-based standardization (predictive margins), were used to estimate proportion differences (PDs) with bias-corrected bootstrapped 95% confidence intervals.
Results: A total of 174 nL black and 160 Latina patients were identified. Between pre- and post-ACA, the overall proportion of uninsured at the time of diagnosis decreased from 36.6% to 20.9% (p=0.00). The decrease in the uninsured population was statistically significant only for Latina women (p=0.00). There was a small shift in early-stage diagnoses. Post-ACA, the overall proportion of Stage I cancers increased from 26.8% to 31.8% (PD=5.0; p=0.33). However, this shift occurred among nL black women (PD=9.6%, p=0.18) but not among Latina women (PD=0.0, p=0.91). This pattern remained even after adjusting for age, insurance status, and history of outpatient preventative care use. Of note, compared with women diagnosed pre-ACA, those diagnosed post-ACA were less likely to have had a preventative care visit during the 24 months prior to diagnosis (26% versus 51%, p=0.00).
Conclusion: Early results suggest that the ACA has increased access to insurance for underserved nL-black and Latina breast cancer patients. However, its impact on preventative care utilization and early cancer diagnosis is unclear. Post-ACA patients might be newly entering the health care system, due to having obtained insurance, and so may need assistance navigating to obtain preventative care, such as mammograms. Next steps include examining changes in screen-detected versus symptom-detected cancer, time to treatment, and conducting semistructured interviews to examine women's experiences with breast cancer care pre- and post-ACA.
Citation Format: Abigail Silva, Arielle Guzman, Charlotte Picard, Yamile Molina, Alexandrina Balanean, Paramjeet Khosla. Did the Affordable Care Act improve insurance coverage and stage at diagnosis among nonelderly underserved breast cancer patients? [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr B076.