The Affordable Care Act (ACA) has increased guideline-concordant care for colorectal cancer among non-White patients, those from rural areas, and those from the most deprived neighborhoods in Pennsylvania, according to new findings presented by Kudaravalli et al at the 2024 American Association for Cancer Research (AACR) Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved (Abstract PR007).
Background
Receiving guideline-concordant care is often associated with improved cancer outcomes—such as survival—and insurance access is an important determinant of receiving guideline-concordant care.
“The ACA was the largest change to the health insurance system in the United States since the introduction of Medicare and Medicaid in the 1960s, but there is limited evidence on how it affected cancer treatment for different patient populations,” explained lead study author Sriya Kudaravalli, a third-year medical student at the University of Pittsburgh School of Medicine. “We were interested in examining changes in receipt of guideline-concordant cancer treatment across various racial and socioeconomic groups after ACA insurance expansions. Understanding these changes can inform future policies to address treatment disparities,” she emphasized.
Study Methods and Results
In the new retrospective study, investigators defined guideline-concordant care for stage III colorectal cancer as the use of adjuvant chemotherapy and the resection of affected regional lymph nodes based on medical literature and the criteria established by the National Comprehensive Cancer Network. They then used the 2010 to 2019 Pennsylvania Cancer Registry to examine the data of 3,290 patients aged 26 to 64 years who were diagnosed with stage III colorectal cancer.
The year the main insurance expansions under the ACA were implemented (2014) served as the cutoff between pre- and post-ACA care. The patients were mostly male (54.5%), non-Hispanic White (79.8%), and residing in urban areas (87.9%). About 4% of them identified as non-Hispanic Black and 3.6% of them were Hispanic—with 7.5%, 2.5%, and 2.1% of the patients living in large towns, small towns, and rural areas, respectively. Each of these variables was balanced between pre- and post-ACA data based on standardized mean differences.
The investigators compared the receipt of guideline-concordant care over the two time periods across several socioeconomic factors, including, age, sex, race/ethnicity, insurance status, community type, and area deprivation index (ADI)—which included variables related to income, education, employment, and housing quality. They grouped ADI scores into quartiles, with ADI quartile 1 representing the least disadvantaged neighborhoods and ADI quartile 4 representing the most disadvantaged neighborhoods.
The investigators noted that 63.7% of the patients in the sample had private insurance, 10.5% of them were covered by Medicare, 11.9% of them were covered by Medicaid, and 13.8% of them were either uninsured or had an insurance status that was unknown or from another source.
Across the entire study period, 82.8% of the patients received guideline-concordant care. However, post-ACA, the receipt of guideline-concordant care increased on average per year by 7.8% among non-White patients, 7.7% among those residing in rural areas, and 3.5% among those in ADI quartile 4 neighborhoods.
Conclusions
Among limitations of the study noted by the researchers, patients with missing variables who were excluded from the final results tended to be from underserved groups, which may have decreased the size of the effect. Additionally, the data came from a single state.
The investigators plan to examine the effect of the ACA on receipt of guideline-concordant care for prostate cancer and lung cancer.
“Implementation of the ACA is associated with an increase in the quality of [colorectal] cancer care for underserved groups,” underscored Ms. Kudaravalli. “Availability of insurance coverage is important for reducing disparities in cancer care and outcomes. States that haven’t yet expanded Medicaid are missing an opportunity to improve access to guideline-concordant treatment for cancer,” she concluded.
Disclosure: The research in this study was supported by the Agency for Healthcare Research and Quality. For full disclosures of the study authors, visit aacrjournals.org.
