Abstract IA32: Con: The ACA will not eliminate disparities in cancer screening
Authors: Taplin Stephen , Abdiwahab Ekland , Gonzales Felisa 
Published: October 2015

Abstract
While hopes have risen that the Affordable Care Act (ACA) will eliminate screening health disparities, we argue that disparities will persist. In this session we will discuss differences in mortality by age and race for breast cancer, colon, and cervical cancer. Let's be clear, however, that differences are not disparities. Biologic differences may account for some differences in morbidity and mortality and these causes cannot be addressed by screening alone. In this discussion we use the term disparity as suggested by Health People 2020 to mean differences due to “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage”.
Though 20 million people have gained coverage under the ACA, that coverage alone will not eliminate health disparities because that is only one factor in a multilevel problem. Factors in multilevel problems interact with each other so the ACA is a major step forward that will affect the healthcare environment in states, healthcare organizations, provider teams and the mind of individuals seeking health. But that is exactly why the ACA is only a start; the ACA will not eliminate the other socio-economic barriers that still exist at those levels and will even increase barriers in some cases; state policies, organizational culture and assets, medical team practices and functioning, and individual attitudes all must be addressed to eliminate differential screening rates and reduce disparities in cancer morbidity and mortality. There has been progress in reducing disparities in screening rates for breast, colorectal, and cervical cancer by some criteria. Screening rates for breast, colorectal, and cervical cancer across race have narrowed according National Health Interview Data through 2011. For example, for breast cancer screening, the proportion of women with a mammogram in the previous 18 months was 37.5% in 2000 for Non-Hispanic Asian Americans and 53.9% for Non-Hispanic Whites. By 2011 the proportions had converged to between 50% and 55% across Hispanic, Non-Hispanic Black, Non-Hispanic White, and Non-Hispanic Asians. A similar convergence is seen for cervical cancer screening as well (40-60%), though the spread across race was less dramatic in 2000 for this cancer. Colon cancer screening rates in the previous year are lowest among the three cancers but the same trend occurs; screening rates varied from 18% among Non-Hispanic Asians to 25% among Non Hispanic Whites in 2000, and converged to 24% and 25% respectively in 2011. Across all three cancers screening rates remained lowest for American Indians and Alaska Natives. The single most important disparity is differential screening rates across educational levels, and educational attainment will not be addressed by the ACA.
To reduce health disparities we must take advantage of the major change that the ACA represents but not assume it will fix the problem of differential screening and mortality due to cancer of the breast, cervix, colon and rectum among people living in the United States. The undocumented aliens in the US will have increased challenges seeking care because they are not eligible for coverage through the ACA. The 22 states that do not expand Medicaid coverage will have persistent health care access issues for low-income women. Furthermore, there are challenges to using our care system and seeking screening once people have coverage. In studies of late-stage breast and invasive cervical cancers occurring among people enrolled in 7 managed care plans for at least 3 years, living in areas of high poverty or having low educational levels were associated with higher risks of invasive cervical cancer (1.72, 95% CI 1.11-2.67; 1.52, 95% CI 1.07-2.16 for high poverty and low income respectively). To address disparities in screening we must address the underlying issues associated with poverty, and low education. More research is needed to understand these associations and consider factors such as organizational culture, physical distance, and social support as they may become more salient determinants of differential screening rates as financial barriers are reduced. We must also, however, continue to recognize that financial barriers exist for some populations, and for some where screening is coverage by diagnostic processes are not.
Citation Format: Stephen Taplin, Ekland Abdiwahab, Felisa Gonzales. Con: The ACA will not eliminate disparities in cancer screening. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr IA32.