Abstract A88: A Preliminary Assessment of the Potential Impact of the Affordable Care Act on Breast Cancer Stage
Authors: Silva Abigail , Markossian Talar , Molina Yamile 
Published: March 2017

Abstract
Background: The Affordable Care Act (ACA) has provided phased-in changes in health care delivery and reimbursement. As of January 1, 2011, the ACA eliminated copayments/co-insurance for recommended preventive services in Medicare beneficiaries including breast cancer screening. Removing out-of-pocket expenses may encourage an uptake of preventative cancer care. Indeed, one study has found that compared with the pre-ACA period (2009-2010), there was a statistically significant increase in mammography uptake during the ACA coverage period (2011-2012). Mammography screening is associated with detection of breast cancer at early stages. Therefore, this provision of the ACA may increase the proportion of early stage diagnoses which are associated with less invasive treatment and improved outcomes. Furthermore, this ACA provision may help ameliorate racial/ethnic disparities in breast cancer stage because minorities are disproportionately represented among those targeted by the coverage provisions of the ACA. The purpose of the present analysis is to examine the impact of the elimination of copayments for screening on breast cancer stage (disparities) in the Medicare population.
Methods: This study is a retrospective analysis of patients with breast cancer diagnosed between 2008 and 2013 who were included in the National Cancer Data Base (NCDB). Sponsored by the Commission on Cancer of the American College of Surgeons and the American Cancer Society, the NCDB is a nationwide cancer database that captures approximately 70% of all newly diagnosed cancers in the United States from approximately 1,500 hospitals accredited by the Commission on Cancer. Patients were included if they were: non-Latina (nL) white, nL black, or Latina; diagnosed with Stage I-IV cancer; Medicare-insured at the time of diagnosis; and age 66 years or older. The pre- and post-ACA periods of the preventative services provision were identified as 2008-2009 and 2011-2013, respectively. The year 2010 wastreated as a washout/phase-in period and was excluded. A pre-post design was used to examine a shift in the distribution of cancer stage and compare changes by race/ethnicity. Proportion differences were calculated. The binomial model with a link function was used to adjust differences by age and zip code-level economic indicators (i.e. median household income, percent with high school education).
Results: We identified 213, 385 nL white, 21,452 nL black, and 7,980 Latina patients with an incident breast cancer diagnosis. Between the pre- and post-ACA periods, there was a statistically significant shift in the distribution of cancer stage. The proportion of Stage I cancers increased from 55.6% to 58.1% while it decreased for Stage II cancers from 29.5 to 27.9% (p&lt;0.0001). The increase in the proportion of Stage I cancer was highest for Latina (50.4% to 55.1%, p&lt;0.0001) and nL black patients (44.5% to 47.9%, p&lt;0.01) and lowest for nL white patients (56.9% to 59.3%, p&lt;0.0001). After adjusting for age, income, and education, these differences were slightly attenuated. In addition, the Latina/nL white proportion difference in Stage I cancer diagnoses was reduced by 2.4 percentage points whereas the nL black/nL white difference was reduced by 0.2 percentage point.
Conclusion: The ACA's elimination of copayments/co-insurance for preventive services such as cancer screening may have a meaningful impact on cancer outcomes. A preliminary assessment shows that it may lead to a shift in earlier stage breast cancers. The elimination of these out-of-pocket expenses for mammograms may particularly benefit Latina women who tend to have lower screening rates. These study findings should be interpreted in light of its limitations such as its cross-sectional design and lack of mammography screening assessment. More research is needed to understand the impact of the ACA on cancer care and outcomes.
Citation Format: Abigail Silva, Talar Markossian, Yamile Molina. A Preliminary Assessment of the Potential Impact of the Affordable Care Act on Breast Cancer Stage. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr A88.