Abstract P6-11-02: The efficacy of the Affordable Care Act (ACA) in reducing disparities in breast cancer
Authors: Sarah Elizabeth Mudra, Shruti Bhandari, Xiaoyong Wu, Shesh Rai, Mounika Mandadi, Elizabeth Carloss Riley
Journal: Cancer Research (2020)

Abstract Background: Disparities in care persist across the health care system. Federal Affordable Care Act (ACA) legislation and state-optional Medicaid expansion aimed to increase insurance coverage and reduce barriers to health care access. The efficacy of the ACA in reducing health disparities and increasing survival in the real-world remains understudied. Methods: Using the National Cancer Database, demographic, clinical and geographic features of 955,596 stage I-III breast cancer patients treated between 2004 and 2014 were examined. A quasi-experimental design via difference-in-differences (DID) was used to evaluate percent change in uninsurance pre- (2004-2010) and post- (2011-2014) ACA. DID analysis was sorted according to race (White, Black, Other) and facility location (Northeast, Midwest, South, West). Results: In this dataset, 85% of patients were white, 11% were black and 4% were categorized as other. Overall, a majority of patients held private insurance (55%) followed by Medicare at 37%, Medicaid at 6% and uninsured at 2%. Post-ACA, change in uninsurance rate was not statistically different as compared to the pre-ACA rate (p=0.191, Table). However, when stratified by race, uninsurance rate in Blacks declined significantly as compared to Whites (p=0.022, Table). By geographic location, the Northeast showed a statistically significant decrease in the rate of uninsurance (p=0.019) post-ACA while the South demonstrated a statistically significant increase in uninsurance rate (p=0.001, Table) post-ACA. The percentage of patients receiving treatment within 30 days of diagnosis significantly decreased post-ACA (45% versus 55% pre-ACA). Yet, upon stratification by race, the percentage of Blacks and those of Other races receiving treatment within 30 days of diagnosis significantly increased post-ACA (Black: 8.9% post-ACA versus 8.4% pre-ACA; Other: 4.1% post-ACA versus 3.3% pre-ACA). Conclusions: Our study of the National Cancer Database indicates that ACA improved racial disparities in breast cancer by significantly decreasing uninsurance rates and treatment delays in minority populations. Careful evaluation of the ACA’s efficacy in subsets of real-world patients remains crucial as health care reform continues. Table. Unadjusted percentage of patients without health insurance (n= 955596). FactorSample Size2004-20102011-2014AD95% CIRCP Value%95% CI%95% CIOverall9555961.93(1.90,1.97)1.97(1.93,2.01)0.04(-0.02,0.09)2.070.191RaceWhite8163551.65(1.61,1.68)1.68(1.64,1.73)0.04(-0.02,0.09)0.020.213Black1013583.76(3.60,3.91)3.48(3.31,3.65)-0.27(-0.50,-0.04)-0.080.022Other378833.72(3.46,3.99)3.58(3.31,3.85)-0.14(-0.52,0.24)-0.040.469Facility locationNortheast1978561.26(1.20,1.33)1.15(1.07,1.22)-0.12(-0.21,-0.02)-0.090.019Midwest2460881.51(1.44,1.57)1.48(1.41,1.56)-0.02(-0.12,0.08)-0.020.669South3531022.91(2.84,2.98)3.10(3.01,3.19)0.19(0.07,0.30)0.070.001West1585501.29(1.21,1.36)1.21(1.13,1.30)-0.07(-0.18,0.04)-0.060.189CI: Confidence Interval, AD: Absolute Difference, RC: Relative Change.Grant Source: NIH/NCI R25-CA134283 Citation Format: Sarah Elizabeth Mudra, Shruti Bhandari, Xiaoyong Wu, Shesh Rai, Mounika Mandadi, Elizabeth Carloss Riley. The efficacy of the Affordable Care Act (ACA) in reducing disparities in breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-11-02.