post-ACA Periods Research Articles

Effects of the Affordable Care Act on Contraception, Pregnancy, and Pregnancy Termination Rates.

To investigate the effects of the Affordable Care Act (ACA) and its elimination of cost-sharing on contraception utilization, pregnancy rates, and abortion rates. We conducted a retrospective cohort study within a healthcare system serving over 4.5 million insured members across 21 medical centers and 250 clinics. The study included women aged 18-45 with continuous health plan membership for at least two years in the pre-ACA (2007-2012) and post-ACA (2013-2018) periods. We analyzed out-of-pocket (OOP) costs for contraception, including oral contraceptives and long-acting reversible contraception (LARC), before and after the ACA's implementation. We then examined how the elimination of OOP costs affected contraception use, pregnancy rates, and abortion rates. The study identified 1,523,962 women of childbearing age. In 2013, cost sharing for contraception sharply declined, with average annual OOP costs dropping from $88-$94 pre-ACA to nearly zero post-ACA. Contraceptive use increased overall, rising from 30.2% pre-ACA to 31.9% by the study's end, with a notable rise in LARC use. In interrupted time-series analyses, while contraception use continued to increase post-ACA, new pregnancy rates declined at a faster rate than pre-ACA, and abortion rates continued to fall, though at a slightly slower pace than pre-ACA (p<0.05 for all trends). The Affordable Care Act's elimination of contraception cost-sharing led to increased contraception use, particularly LARC methods, and contributed to declines in both pregnancy and abortion rates. This suggests that improving access to effective contraception is a key strategy in reducing unintended pregnancies.

Impact of the Implementation of the Affordability Care Act on Gastric Cancer Survival Rates.

Introduction Gastric cancer, a significant public health concern, remains one of the most challenging malignancies to treat effectively. In the United States, survival rates for gastric cancer have historically been low, partly due to late-stage diagnosis and disparities in access to care. The Affordable Care Act (ACA)sought to address such disparities by expanding healthcare coverage and improving access to preventive and early treatment services. Objective This study aims to determine the causal effects of the ACA's implementation on gastric cancer survival rates, focusing on a comparative analysis between two distinct U.S. states: New Jersey, which fully embraced ACA provisions, and Georgia, which has not adopted the policy, as of 2023. Methods In this retrospective analysis, we utilized data from the Surveillance, Epidemiology, and End Results Program (SEER) registry to assess the impact of the ACA on cancer-specific survival (CSS) among gastric cancer patients. The study spanned the period from 2000 to 2020, divided into pre-ACA (2000-2013) and post-ACA (2016-2020) periods, with a two-year washout (2013-2015). We compared Georgia (a non-expansion state) to New Jersey (an expansion state since 2014) using a Difference-in-Differences (DiD) approach. We adjusted for patient demographics, income, metropolitan status, disease stage, and treatment modalities. Results Among 25,061 patients, 58.7% were in New Jersey (14,711), while 41.3% were in Georgia (10,350). The pre-ACA period included 18,878 patients (40.0% in Georgia and 60.0% in New Jersey), and 6,183 patients were in the post-ACA period (45.2% in Georgia and 54.8% in New Jersey). The post-ACA period was associated with a 20% reduction in mortality hazard among gastric cancer patients, irrespective of the state of residence (HR = 0.80, 95% CI: 0.73-0.88). Patients who were residents of New Jersey experienced a 12% reduction in mortality hazard compared to those who resided in Georgia in the post-ACA period (HR = 0.88, 95% CI: 0.78-0.99). Other factors linked to improved survival outcomes included surgery (OR = 0.30, 95% CI: 0.28-0.34) and female gender (OR=0.83, 95% CI: 0.76-0.91). Conclusion The study underscores the ACA's potential positive impact on CSS among gastric cancer patients, emphasizing the importance of healthcare policy interventions in improving patient outcomes.

Effect of the Affordable Care Act on Cervical Cancer Survival Rates in Californian Women [ID 2683402

INTRODUCTION: Following the Affordable Care Act (ACA), insurance coverage among women in California surged. While ACA aimed to boost health care access and utilization, whether this has improved cancer-specific survival rates for cervical cancer patients remains questioned. In the present study, we evaluate the effect of the Affordable Care Act (ACA) on cancer-specific survival rates among women with cervical cancer by comparing pre-ACA (2000–2009) and post-ACA (2010–2020) periods. METHODS: This study utilized data from the Surveillance, Epidemiology, and End Results (SEER) Registry from 2000 to 2020. We bifurcated the study duration into pre-ACA (2000–2009) and post-ACA (2010–2020). The primary outcome investigated was cancer-specific survival between these periods. Our objective was to assess the effect of ACA's implementation on cancer-specific survival among women diagnosed with cervical cancer. Analytical adjustments were made for patient age, race/ethnicity, disease stage at presentation, income, marital status, and metropolitan residence status. We also considered whether cervical cancer was the primary site and incorporated treatment modalities such as curative surgery, radiotherapy, and chemotherapy into our analysis. RESULTS: Of 29,402 cervical cancer patients, 15,962 were diagnosed pre-ACA and 13,440 post-ACA. More women over 50 were diagnosed post-ACA (49.4%) than pre-ACA (44.9%). Late-stage diagnoses rose slightly post-ACA (42.7% versus 40.8%). Curative surgery decreased post-ACA (53.7% from 62.7%), but chemotherapy increased (48.6% from 39.9%). After adjusting for treatment modalities, post-ACA survival rates in California mirrored those of the pre-ACA period (hazard ratio [HR] 1.06; 95% CI, 0.98–1.15). CONCLUSION: The implementation of the ACA led to notable changes in treatment patterns and demographics for cervical cancer patients in California. Although health care access increased, cancer-specific survival rates were similar to the pre-ACA period when adjusting for treatment modalities.

Medicaid Expansion and Cervical Cancer Survival: A Comparative Analysis of Expansion Compared With Non-expansion States Using the SEER Registry [ID 2683647

INTRODUCTION: Medicaid expansion under the Affordable Care Act sought to improve access to care for millions of uninsured Americans. The implications of this policy change on patients with cervical cancer, a condition disproportionately affecting socioeconomically disadvantaged women, remains underinvestigated. This study explores the effect of Medicaid expansion on cancer-specific survival. METHODS: Using the SEER registry, we retrospectively analyzed cervical cancer patients from a non-expansion state (Georgia), and states that experienced Medicaid expansion (California, Connecticut, Louisiana, etc.). The study spans from 2000 to 2020. We divided the data into pre-ACA (before 2010) and post-ACA (after 2010) periods. Cancer-specific survival was our primary outcome. A difference-in-differences analysis was conducted, adjusting for age, race, income, disease stage, marital status, and regional characteristics. RESULTS: Among 63,796 cervical cancer patients, 55,683 (87.3%) were from Medicaid expansion states and 8,184 (12.7%) from non-expansion Georgia. The 5-year survival was 68.5% in expansion states versus 68.4% in Georgia (P&gt;.05). Difference-in-differences analysis revealed no significant effect of policy implementation on cancer-specific survival (hazard ratio [HR] 1.01; 95% CI, 0.90–1.13). Surgical treatment significantly predicted improved survival (HR 0.46; 95% CI, 0.44–0.49). Black women had lower survival than White women (HR 1.18; 95% CI, 1.12–1.25). CONCLUSION: Medicaid expansion under the Affordable Care Act showed no significant effect on cervical cancer-specific survival. Surgical treatment improved survival, while Black women experienced comparatively lower survival rates.

Factors in Hand Surgery Access for Rheumatoid Arthritis Before vs After the Patient Protection and Affordable Care Act

Rheumatoid arthritis (RA) has severe functional and economic consequences. The implications of the Patient Protection and Affordable Care Act (ACA) and demographic factors for access to surgical treatment are unclear. To investigate factors associated with time to RA hand surgery, surgical incidence, and cost after implementation of the ACA. This cross-sectional study used insurance data from the IBM MarketScan Research Databases from 2009 through 2020 to compare time to surgery, surgical incidence, and treatment cost for RA of the hand before and after ACA implementations. Included patients were 18 years or older with a new diagnosis for RA of the hand and at least 1 procedural code for arthroplasty, arthrodesis, tenolysis, tendon repair, or tendon transfer. Patients with coexisting inflammatory arthritis diagnoses were excluded. Demographic variables analyzed included patient sex, age at index date, residence within or outside a metropolitan statistical area (MSA; hereafter urban or nonurban), insurance and health plan type, Social Deprivation Index, Elixhauser Comorbidity Index score, and Rheumatic Disease Comorbidity Index. Data analysis occurred from October 2022 to April 2023. Surgery for RA of the hand during the pre-ACA (before 2014) vs post-ACA (2014 or later) periods. Time to surgery, surgical incidence, and cost of treating RA in patients undergoing hand surgery for RA. Among 3643 patients (mean [SD] age, 57.6 [12.3] years) who underwent hand surgery for RA, 3046 (83.6%) were women. Post-ACA passage, 595 (86.2%) patients who resided in urban areas had a significantly lower time to surgery than those who did not (-70.5 [95% CI, -112.6 to -28.3] days; P < .001). Among urban patients, the least socially disadvantaged patients experienced the greatest decrease in time to surgery after ACA but the change was not statistically significant. For all patients, greater social disadvantage (ie, a higher SDI score) was associated with a longer time to surgery in the post-ACA period; for example, compared with the least socially disadvantaged group (SDI decile, 0-10), patients in SDI decile 10 to 20 waited an additional 254.0 days (95% CI, 65.2 to 442.9 days; P = .009) before undergoing surgery. Compared with the pre-ACA period, the mean surgical incidence in the post-ACA period was 83.4% lower (162.3 vs 26.9 surgeries per 1000 person-years; P < .001), and surgical incidence was 86.3% lower in nonurban populations (27.2 vs 3.7 surgeries per 1000 person-years; P < .001) but only 82.8% lower in urban populations (135.1 vs 23.2 surgeries per 1000 person-years; P < .001). Per capita total costs of all treatment related to RA of the hand decreased in the post-ACA period but the change was not statistically significant. Insurer-paid costs were lower in the post-ACA period but the change was not statistically significant. Out-of-pocket expenses did not change. Findings of this cross-sectional study suggest that after ACA passage, disparities exist in access to timely, cost-effective hand surgery for RA. Increased access to surgical hand specialists is needed for nonurban residents and those with greater social deprivation, along with insurance policy reforms to further decrease out-of-pocket spending for RA hand surgery.

Causal Effects of the Affordable Care Act (ACA) Implementation on Non-Hodgkin's Lymphoma Survival: A Difference-in-Differences Analysis.

Non-Hodgkin's Lymphoma (NHL) accounts for a substantial number of cancer cases in the United States, with a significant prevalence and mortality rate. The implementation of the Affordable Care Act (ACA) has the potential to impact cancer-specific survival among NHL patients by improving access to healthcare services and treatments. This study aims to assess the impact of the implementation of the ACAon cancer-specific survival among patients diagnosed with NHL. In this retrospective analysis, we leveraged data from the Surveillance, Epidemiology, and End Results (SEER) registry to assess the impact of the ACAon cancer-specific survival among NHL patients. The study covered the years 2000-2020, divided into pre-ACA (2000-2013) and post-ACA (2017-2020) periods, with a three-year washout (2014-2016). Using a Difference-in-Differences approach, we compared Georgia (a non-expansion state) to New Jersey (an expansion state since 2014). We adjusted for patient demographics, income, metropolitan status, disease stage, and treatment modalities. Among 74,762 patients, 56.2% were in New Jersey (42,005), while 43.8% were in Georgia (32,757). The pre-ACA period included 32,851 patients (51.7% in Georgia and 56.7% in New Jersey), and 27,447 patients were in the post-ACA period (48.3% in Georgia and 43.4% in New Jersey). The post-ACA period exhibited a 34% survival improvement (OR=0.66, 95% CI 0.58-0.75). ACA implementation was associated with a 16% survival boost among NHL patients in New Jersey (OR=0.84, 95% CI 0.74-0.95). Other factors linked to improved survival included surgery (OR=0.86, 95% CI 0.81-0.91), radiotherapy (OR=0.77, 95% CI 0.72-0.82), and married status (OR=0.67, 95% CI 0.64-0.71). The study underscores the ACA's potential positive impact on cancer-specific survival among NHL patients, emphasizing the importance of healthcare policy interventions in improving patient outcomes.

The impact of the affordable care act on access to bariatric surgery in Maryland

IntroductionThis study aims to investigate the influence of the Affordable Care Act (ACA) on the utilization of Roux-en-Y gastric bypass (RYGB) procedures in Maryland. MethodsUsing the Maryland State Inpatient Database, this retrospective study compared all patients undergoing RYGB during the pre-ACA (2007–2009) and post-ACA (2018–2020) periods, including patient demographic factors, pre-existing conditions, and socioeconomic factors. ResultsA total of 16,494 RYGB procedures were performed during the study period, of which 12,089 (73.3 ​%) were post-ACA. This was a 179.2 ​% increase in patients undergoing RYGB post-ACA; nearly triple that of the pre-ACA period. There was a significant decrease in uninsured patients (5.6 ​%–1.5 ​%, p ​< ​0.01) an increase in Black patients (32.1 ​%–46.8 ​%, p ​< ​0.01) and Medicaid beneficiaries (6.0 ​% pre-ACA to 17.8 ​% post-ACA, p ​< ​0.01). There were significant reductions in adverse outcomes (long hospital stays, hemorrhage, GIT leaks, and mortality) across all insurance types (all p ​< ​0.01). ConclusionThe ACA increased access to RYGB procedures, especially in Black and Medicaid recipients in Maryland, enhancing healthcare across all insurance types.

Racial and Ethnic Segregation in Primary Care and Association of Practice Composition With Quality of Care.

To assess the extent of segregation between racial and ethnic minority and White patients across primary care physicians and the association of practice panel racial/ethnic composition with the quality of care delivered. We examined the degree of racial/ethnic dissimilarity (a measure of segregation) in visits and the allocation of patient visits by different groups across primary care physicians (PCPs). We assessed the regression-adjusted relationship between the racial/ethnic composition of PCP practices and measures of the quality of care delivered. We compared outcomes in the pre-Affordable Care Act (ACA) and post-ACA (2006-2010/2011-2016) periods. We analyzed data on all primary care visits to office-based practitioners in the 2006-2016 National Ambulatory Medical Care Survey. PCPs were defined as general/family practice or internal medicine physicians. We excluded cases with imputed race or ethnicity information. For the quality of care analyses, we limited the sample to adults. Racial and ethnic minority patients remain concentrated within a small group of PCPs: 35% of PCPs accounted for 80% of non-White patients' visits; 63% of non-White (or White) patients would need to switch physicians to make the distribution of visits across PCPs proportional between the groups. We observed little correlation between the PCPs panel's racial/ethnic composition and quality of care. These patterns did not change substantially over time. PCPs remain segregated, but the racial/ethnic composition of a practice panel is not associated with the quality of health care that individual patients receive in either the pre or post-ACA passage periods.

The Impact of the Affordable Care Act on Insurance Coverage and Stage Among Head and Neck Squamous Cell Carcinoma Patients.

The purpose was to examine the change in percent uninsured and if there is change in T-stage, N-stage and overall-stage among nonelderly patients with newly diagnosed head and neck squamous cell carcinoma after the Affordable Care Act (ACA). The National Cancer Database was used for this study. Patients were divided between pre-ACA and post-ACA implementation with stratification between areas of ACA expansion versus non-expansion. A quasi-experimental difference-in-difference study design was undertaken. A total of 15,037 patients met the inclusion criteria. Between the pre-ACA and post-ACA periods, there was increase in proportion of percent insured with Medicaid coverage in patients residing in expansion region. There was a decrease in the proportion of patients who had advanced Tumor stage and Nodal stage decreased after implementation of ACA. With the implementation of ACA expansion, there is increased Medicaid coverage, corresponding to a decreased proportion of patients presenting with advanced T-stage and N-stage.

Shoulder MRI lag times after implementation of the Affordable Care Act (ACA): a retrospective review

Background: With the Affordable Care Act (ACA), the challenge of expanding healthcare insurance to Americans without jeopardizing quality of care remains. This study was initiated to evaluate how the timing of magnetic resonance imaging (MRI) completion for shoulder pathology correlates with implementation of the ACA by comparing lag times between the initial visit and the date of MRI completion. In addition, the access to orthopaedic care after ACA implementation was evaluated by comparing shoulder MRI lag times among three cohorts based on insurer status. Methods: All shoulder and proximal upper extremity MRIs between 2009 and 2017 were reviewed, 5 yr before and 3 yr after ACA implementation. Patients were grouped into commercial, Medicare, and Medicaid cohorts. Average lag times for the pre- and post-ACA periods overall and among payor cohorts were calculated. Results: Included were 5900 MRIs, 1997 (33.8%) before and 3903 (66.2%) after ACA implementation. The difference in payor mix before and after ACA implementation was significantly different (P&lt;0.001). Median lag time increased from 23 days pre-ACA to 31 days post-ACA (P&lt;0.001). For commercial insurance, median lag time was 23 days pre-ACA compared with 28 days (P&lt;0.001) post-ACA. Median lag time pre- and post-ACA in the Medicaid cohort was 8 days compared with 30.5 days (P&lt;0.001), respectively. Pre- and post-ACA lag times in the Medicare cohort did not differ significantly (P=0.450). Conclusions: Lag times increased significantly after ACA implementation in patients with commercial and Medicaid insurance. This study provides valuable insight into unintended outcomes associated with the ACA legislation. Level of Evidence: Level III.

Racial and Ethnic Inequities in Financial Hardship Among CVD Patients in the USA During the Pre- and Post-Affordable Care Act Era.

The Affordable Care Act (ACA) has substantially expanded access to health insurance coverage, resulting in a reduction in financial hardship, defined as ability to pay medical bills, among cardiovascular disease (CVD) patients in the post-ACA era. However, it is not known whether implementation of the ACA improved the racialandethnic inequity in financial hardship among CVD patients. As such, using data from the 2011 to 2018 waves of the National Health Interview Survey (NHIS), this paper aims to assess the odds of facing financial hardship among non-Hispanic-White, -Black, -Asian, and Hispanic CVD patients, before and after the implementation of the ACA. Our sample consists of 12,688 CVD patients in pre-ACA (2011-2013), 9128 CVD patients in early (2014-2015), and 11,863 CVD patients in later phase of the ACA (2016-2018). We performed multivariable logistic regressions to examine how the odds, in favor of facing financial hardship, varied between non-Hispanic White and other race/ethnic categories across the pre- and post-ACA periods. Though the overall prevalence of financial hardship was reduced from 22 to 18%, a considerable disparity between Black and Hispanic, and White CVD patients persisted from pre-ACA to post-ACA periods. The odds of experiencing financial hardship for Black and Hispanic CVD patients were, respectively, 2.25 to 2.16 and 1.52 to 1.78 times that of their White counterparts across the periods. Though the ACA is a positive step towards improving healthcare access and affordability, further initiatives are needed to reduce inequities across racial and ethnic minorities.

Annual Wellness Visits for Persons With Physical Disabilities Before and After ACA Implementation.

Persons with disabilities often experience uncoordinated health care, with repeated out-of-pocket copays. One purpose of the Patient Protection and Affordable Care Act (ACA) was to create zero copays for preventive health care including an annual wellness visit (AWV). The purpose of this study was to document the use of AWVs by persons with physical disabilities during the ACA rollout. An administrative claims database, including both Medicare Advantage (MA) and commercial (COM) payers from 2008 to 2016, was used to identify unique wellness visits for adults with physical disabilities. We used interrupted time series analysis to compare AWV use by insurance type, sex, disability type, and race over time. The proportion of zero copays provided a timeline of ACA implementation categorized as pre-ACA, ACA-implementation, and post-ACA periods. By 2016, AWV use maximized at 47.6% (95% CI, 44.7%-50.8%) among COM-insured White women with congenital disabilities. By 2016, the lowest AWV use reached one-half the maximum, at 21.6% (95% CI, 18.4%-25.2%) among COM-insured Hispanic men with acquired disabilities. MA-insured Black and Hispanic men with acquired disabilities reached similarly low levels of AWV use. The ACA mandated zero copays, thereby allowing persons with physical disabilities the option for preventive health care without cost. Insurance type and sex significantly influenced AWV use, followed by disability type and race. Gaps in AWV use were exposed by insurance type, sex, disability, and race for persons with disabilities. Gaps in AWV use were also exposed between the general population and persons with disabilities.Annals "Online First" article.

The Affordable Care Act and Health Care Access and Utilization Among White, Asian, and Latino Immigrants in California.

The objective of this study was to examine changes in health care access and utilization for White, Asian, and Latino immigrants associated with the implementation of the Patient Protection and Affordable Care Act (ACA) in California. Using the 2011-2013 and 2015-2017 California Health Interview Survey, we examined changes in 2 health care access and 2 utilization measures among 3 immigrant racial/ethnic groups. We estimated the unadjusted and adjusted percentage point changes in the pre-ACA and post-ACA periods. Adjusted estimates were obtained using linear probability models controlling for predisposing, enabling, and need factors. After the ACA was nationally implemented in 2014, rates of insurance increased for non-Latino (NL) White, NL Asian, and Latino immigrant groups in California. Latino immigrants had the largest increase in insurance coverage (14.3 percentage points), followed by NL Asian immigrants (9.9 percentage points) and NL White immigrants (9.2 percentage points). Despite benefitting from the largest increase in insurance coverage, the proportion of insured Latino immigrants was still lower than that of NL White and NL Asian immigrants. Latino immigrants reported a small but significant decrease in the usual source of care (-2.8 percentage points) and an increase in emergency department utilization (2.9 percentage points) after the ACA. No significant changes were found after the ACA in health care access and utilization among NL White and NL Asian immigrants. Insurance coverage increased significantly for these 3 immigrant groups after the ACA. While Latino immigrants had the largest gain in insurance coverage, the proportion of Latino immigrants with insurance remained the lowest among the 3 immigrant racial/ethnic groups.

Implementation of insurance marketplaces and changes in diagnosis stage in low-income cancer patients.

1576 Background: Millions of low-income Americans gained insurance coverage through Medicaid expansion and the “Marketplaces” of the Affordable Care Act (ACA). How Marketplaces have specifically improved cancer outcomes among these individuals is unclear. Thus, we examined changes in insurance status and diagnosis stage following the ACA among low-income (139-250% of the Federal Poverty Level [FPL]), non-elderly patients (ages 30-64). Methods: In Ohio’s cancer registry, we identified patients diagnosed with one of the top 16 cancers before (2011-2013, “Pre-ACA”) and after (Q3 of 2014-2016, “Post-ACA”) the implementation of the ACA’s insurance Marketplaces and either had private insurance or no insurance. Low-income patients were isolated using a novel, geographically-driven approach called probability weighting. Results: The uninsured percentage dropped from 12.9% to 4.9% between the Pre- and Post-ACA periods in the study sample (N = 10,747). An estimated 11.1% of individuals had Marketplace insurance Post-ACA. A significant but modest Post-ACA (versus Pre-ACA) shift toward non-metastatic disease was identified (Adjusted Odds Ratio [AOR]: 0.95, 95%CI: 0.90-0.99). The largest site-specific shifts were observed for thyroid (AOR: 0.50, 95%CI: 0.30-0.83) and ovarian (AOR: 0.74, 95%CI: 0.58-0.93) cancers. In a control analysis of wealthier (400%+ FPL), privately insured individuals, no significant shifts were identified (AOR: 0.97, 95%CI: 0.92-1.02). Conclusions: This is the first study to show an effect in cancer stage at diagnosis from the Affordable Care Act’s Insurance Marketplaces. We found that the Marketplaces greatly reduced the number of low-income, uninsured cancer patients, translating to significant improvements in cancer stage at diagnosis. As policy makers contemplate modifications to the ACA, they should carefully consider the impact of those changes on the highly vulnerable population of low-income cancer patients.

4498 The Effect of the Affordable Care Act on the Stage at Diagnosis in Low income Privately Insured Cancer Patients, including those with Marketplace coverage

OBJECTIVES/GOALS: The goal of this study was to examine the change in the odds of being diagnosed with metastatic cancer after the Affordable Care Act (ACA) among low-income, privately insured, nonelderly patients with newly diagnosed cancer. Low-income was defined as having income&lt;250% FPL (federal poverty level). METHODS/STUDY POPULATION: Using Ohio cancer registry data linked with census tract-level income data, individuals aged 18-64 years diagnosed with one of the 15 leading cancers and reported being privately insured or uninsured were identified. Low-income patients were isolated using probability weighting, a process in which each observation was assigned a weight equal to the probability of a patient having an income &lt;250% FPL based on the patient’s census tract of residence. Then, a multivariable logistic model was fitted to examine the independent association between the exposure (Post-ACA, years 2015-2016 versus Pre-ACA, years 2012-2013) and the outcome (metastatic versus non-metastatic disease at diagnosis). RESULTS/ANTICIPATED RESULTS: Between the Pre-ACA and Post-ACA periods, the percent uninsured in the low-income study population decreased from 14.1% to 4.5% (p &lt;0.01). In the Post-ACA period, among those with insurance coverage, an estimated 11.7% of individuals had Marketplace coverage. After adjusting for potential confounders (sex, age, race-ethnicity, marital status, community-level income, rurality, and cancer type), individuals diagnosed Post-ACA had 5% lower odds of having metastatic disease relative to Pre-ACA (Adjusted Odds Ratio: 0.95, 95% Confidence Interval: 0.91 - 0.99, p = 0.04). DISCUSSION/SIGNIFICANCE OF IMPACT: The shift towards non-metastatic disease likely reflects increases to coverage brought on by the marketplaces. However, the shift is smaller than those observed in Medicaid enrollees, suggesting that policy refinements in the marketplaces can further improve outcomes in low-income cancer patients.

Abstract B076: Did the Affordable Care Act improve insurance coverage and stage at diagnosis among nonelderly underserved breast cancer patients?

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.

Abstract B079: The Affordable Care Act and cancer stage in an underserved population

Abstract Background: The Patient Protection and Affordable Care Act (ACA), particularly provisions enacted in 2014 including the health insurance exchange and Medicaid expansion, aimed to reduce the number of uninsured individuals in the United States. The ACA has increased insurance coverage and improved cancer stage at diagnosis for certain populations, but unknown is the effect of ACA on cancer stage at diagnosis specifically among the underserved (i.e., socioeconomically disadvantaged). Therefore, we aimed to assess the effect of ACA enactment on advanced-stage cancer diagnosis among underserved cancer patients. Methods: We used data from the JPS Center for Cancer Care institutional registry (accredited by the Commission on Cancer). This center is part of an urban public hospital network that serves Tarrant County, TX (population &amp;gt;2 million) and is a primary source of care for underserved individuals. Our eligible population included individuals aged ≥18 years who were diagnosed with a first primary solid malignancy between 2008 and 2015. We compared the effect of ACA implementation on advanced stage diagnosis for overall, screen-detectable, and non-screen-detectable cancers using a natural experiment framework and interrupted time-series analysis to estimate prevalence differences (PD) and 95% confidence limits (CL), where January 2014 differentiated the pre- and post-ACA periods in 6-month intervals. Results: Our study population comprised 6,679 underserved patients, of whom 46% were aged &amp;lt;55 years, 55% were female, 25% were non-Hispanic Black, and 24% were Hispanic. Private insurance coverage increased from 4.6% to 10% after ACA enactment. The overall prevalence of advanced stage diagnosis increased 2.5% following ACA enactment (95% CL: -2.0%, 7.0%), which modestly varied for screen-detectable cancers (PD = 4.3%, 95% CL: -0.3%, 8.8%) and non-screen-detectable cancers (PD = 1.4%, CL: -3.7%, 6.6%). Discussion: Our results do not suggest a reduction in late-stage diagnosis after ACA enactment among underserved cancer patients. The small increase in prevalence of late-stage diagnosis post-ACA could be an initial consequence of increased access to care (i.e., recognition of previously undiagnosed cases) given the small increase in private insurance coverage, but longer follow-up is necessary to interpret this result. Texas did not expand Medicaid coverage as part of ACA enactment, and thus our findings raise questions about whether Medicaid expansion would have affected late-stage diagnosis among underserved cancer patients. Citation Format: Yan Lu, Bradford E. Jackson, Deanna Cross, Latha Neerukonda, Bhavna Tanna, Bassam Ghabach, Rohit P. Ojha. The Affordable Care Act and cancer stage in an underserved population [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 B079.

The association between health care coverage and prevalence of cardiovascular diseases and diabetes over a 10-year period.

Persons without health care coverage have poorer health outcomes. We investigated the association between health care coverage and trends in the prevalence of cardiovascular disease (CVD) and diabetes pre- and post-Affordable Care Act (ACA) periods. Using data from 3,824,678 surveyed adults in the Behavioral Risk Factor Surveillance System survey from 2007 – 2016, we calculated the yearly prevalence of CVD and diabetes. Using logistic regression, we investigated the association between health care coverage and CVD and diabetes, controlling for sociodemographic factors (age, sex, race, marital status, education and income). The mean age of participants was 55.3 ± 18.9 years. Health care coverage increased from 88.6% in 2007 to 93% in 2016. The prevalence of CVD and diabetes increased from pre- to post-ACA periods. After adjustment, in pre-ACA period, the odds ratio (OR) for the association between health care coverage and CVD and diabetes was 1.32 (95% CI:1.30–1.34) and 1.44 (95% CI:1.41–1.46), respectively; in the post-ACA period, the OR was 1.26 (95% CI:1.22–1.30) and 1.48 (95% CI:1.44–1.52), respectively. We found a significant association between health care coverage and trends in the prevalence of CVD and diabetes in the pre- and post-ACA periods.

The Ecology of Medical Care Before and After the Affordable Care Act: Trends From 2002 to 2016.

The initial ecology of medical care study was published in 1961, offering a framework by which to investigate individuals' contact with the medical system. We studied changes in the framework around the implementation of the Patient Protection and Affordable Care Act (ACA) within longer-term trends. The 2002-2016 Medical Expenditure Panel Survey was used to determine rates of visit/contact per 1,000 individuals per month for physicians, primary care physicians, specialty physicians, emergency departments, inpatient hospitalizations, dental visits, and home health visits for the overall population and by age group, poverty category, health status, and race/ethnicity. Adjusted Wald tests were used to investigate differences between the pre-ACA (2012-2013) and post-ACA (2014-2015) periods. Multivariable linear regression was used to determine trends over the study period (2002-2016). The survey included 525,804 person-years. The uninsured rate decreased from 12.8% (95% CI, 12.0%-13.7%) in 2013 to 7.6% (95% CI, 7.0%-8.3%) in 2016. From 2002 to 2016, the numbers of individuals in a month who had contact with primary care physicians, dental care, and inpatient hospitalizations decreased. Primary care physician contact decreased most among the elderly and those reporting fair/poor health. After ACA implementation, few significant changes were identified in the overall population or by age, poverty category, race/ethnicity, or health status. The medical ecology framework was not notably altered 2 years after implementation of the ACA. The long-term decrease in primary care contact does not appear to have been interrupted after implementation of the ACA, was observed across income and age categories, and was most evident among the elderly and individuals reporting fair/poor health.

Socioeconomic and Demographic Variation in Insurance Coverage Among Patients With Head and Neck Cancer After the Affordable Care Act

Health insurance status has a significant association with early diagnosis and stage at presentation, which are the most important predictors of survival among patients with head and neck cancer (HNC). Literature on the association of the Patient Protection and Affordable Care Act (ACA) with changes in insurance status among patients with HNC remains limited. To our knowledge, no studies have evaluated changes in insurance rates across sociodemographic subgroups of patients with HNC. To assess the association of the implementation of the ACA with insurance status across socioeconomic and demographic subpopulations of patients with HNC. A retrospective cohort study using data from the National Cancer Database (NCDB), a hospital-based cancer registry (2011-2015) for adults diagnosed with a malignant primary HNC was carried out. The analyses were conducted from November 2018 through December 2018. Changes in the percentage of patients with insurance. A total of 131 779 patients with HNC were identified in the pre-ACA (77 071) and post-ACA (54 708) periods. Overall, 98 207 (74.5%) participants were men and 33 572 (25.5) were women, with 73 124 (55.5%) being aged between 50 to 64 years. There was a 2.68 percentage point decrease (PPD) (95% CI, 2.93-2.42) in the percentage of patients with HNC without insurance from the pre-ACA to the post-ACA period. Changes in the percentage of uninsured patients varied significantly by age, with the largest reduction in uninsured status among patients with HNC aged 18 to 34 years (5.12 PPD; 95% CI, 3.18-7.06) and the smallest reduction in uninsured among those aged 65 to 74 years (0.24 PPD; 95% CI, 0.03-0.45). There was a significantly greater reduction in uninsured status in low-income zip codes (3.45 PPD; 95% CI, 2.76-4.14) than in high-income zip codes (1.99 PPD; 95% CI, 1.63-2.36). There was a significant association between ACA implementation and percentage decrease in uninsured patients. Young adults and those residing in low-income zip codes experienced a significantly higher rate of insurance uptake compared with older adults and residents of high-income areas. This suggests that coverage expansions enacted through the ACA are not only associated with increased access to care among the broader HNC population, but that they may also yield a greater benefit among subpopulations with historically limited insurance coverage.