Access to Health Insurance Reduces Disparities in Cancer Care: The Case for the ACA

August 2019, Vol 12, Special Issue: Payers' Perspectives In Oncology: ASCO 2019 Highlights - Disparities in Oncology
Phoebe Starr

Chicago, IL—Much has been written about racial disparities in cancer care and its outcomes, with some healthcare stakeholders proposing that there may be biological and/or socioeconomic differences that account for this disparity. However, a new study presented at ASCO 2019 suggests that the main explanation is simple—limited access to cancer care accounts for most of the disparity seen between African-American and white patients with cancer.1

The study, which was presented at the plenary session of ASCO 2019 and was featured at the official press conference, showed that the expansion of Medicaid in 2010 under the Affordable Care Act (ACA) nearly erased racial disparities in cancer care.

First Study of This Nature Presented at Plenary Session

This is the first time in recent memory that ASCO’s plenary session featured a study that was not related to new drugs or a change in cancer care practice. The study results underscore the importance of access to health insurance in determining how well patients of all races receive proper cancer care.

“If you can’t access care, you can’t benefit from care,” said Richard L. Schilsky, MD, FACP, FSCT, FASCO, ASCO’s Senior Vice President and Chief Medical Officer, during the press conference. “For all the advances we’ve observed in recent years in cancer treatment, in cancer care broadly speaking, if you don’t have insurance, if you can’t access care, if you can’t get care in a timely fashion, you can’t benefit.”

Flatiron Health researchers examined blinded electronic health records (EHRs) in the company’s database of people diagnosed with cancer who received treatment at 280 community-based cancer centers or academic medical centers, for a total of 800 sites of care. The analysis included 30,386 patients aged 18 to 64 years who were diagnosed with advanced or metastatic solid tumors between January 2011 and January 2018. The cancer types included lung, breast, urothelial, gastroesophageal, colorectal, renal cell, prostate, and melanoma.

Impact of Medicaid Expansion

The researchers reviewed the EHRs of 18,678 patients who received cancer treatment before 33 states expanded access to Medicaid under the ACA, and in states that chose not to expand Medicaid, and compared them with data of 11,708 patients who received treatment in states that did expand Medicaid under the ACA.

Among patients who received treatment in states without a Medicaid expansion or before Medicaid expansion, white patients received systemic therapy within 30 days of their cancer diagnosis 48.3% of the time compared with 43.5% of African-American patients, for an absolute 4.8-point difference.

In states where Medicaid was ex­pand­ed under the ACA, the 4.8-point difference was almost completely erased, resulting in a 0.8-point difference between timely cancer care for African Americans and whites. Timely treatment was delivered to 50.3% of white patients and to 49.6% of African-American patients in states that expanded Medicaid.

“This study extends prior evidence regarding the effect of the ACA and tells us that national healthcare coverage policies may reduce disparities. EHRs can be a valuable resource for research on treatment patterns, disparities, and interventions,” said Amy Davidoff, PhD, MS, Senior Research Scientist in Public Health, Yale School of Public Health, New Haven, CT, and lead author of the study.

At the press conference, ASCO Expert William Dale, MD, PhD, Arthur M. Coppola Family Chair in Supportive Care Medicine, City of Hope, Duarte, CA, commented on the study.

“This work is to be commended. This is some of the best evidence we have to date that policies can impact outcome, particularly timely treatment. Everyone benefits and has some level of improvement,” Dr Dale said.

“People falling behind before they had access to care, and disparity disappeared after Medicaid expansion. It is very impressive to see a notable change that was statistically significant. I love when we have evidence like this to inform policy,” he told listeners.

ACA Enhances Ovarian Cancer Diagnosis

A separate study also presented at ASCO 2019 and featured at the press conference showed that the ACA led to a substantial increase in the diagnosis of early-stage (stages I and II) ovarian cancer in women younger than age 65 years compared with older women.2

Over time, younger women had a 1.7% gain in early-stage diagnosis compared with older women. In addition, a 1.6% improvement was found for younger women who received treatment within 30 days of diagnosis compared with women aged 65 years and older.

Publicly insured women had the greatest magnitude of benefit after the ACA was adopted, with gains of 2.5% in early-stage diagnosis and timely treatment compared with women aged 65 years and older. Although these percentages appear small, they affect a large number of patients.

“More than 22,000 women will be diagnosed with ovarian cancer this year, and half will be dead in 5 years. We have no screening methods for detection, and by the time patients are symptomatic, the disease is diagnosed at an advanced stage,” explained Anna Jo Smith, MD, MPH, MSc, Resident, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, and lead author of the study. “We were interested in determining what the impact of ACA was on earlier stage at diagnosis and treatment of ovarian cancer, since the ACA improves access to care and primary care.”

The study included data from women in the National Cancer Institute database who were diagnosed and received treatment for ovarian cancer between 2004 and 2009 (pre-ACA; 35,842 patients), and between 2011 and 2014 (post-ACA; 37,145 patients). The stage at diagnosis and time to treatment were assessed for women aged 21 to 64 years and compared with a group of women aged 65 years and older (controls, who had access to Medicare and were more likely to be insured pre- and post-ACA).

“The implication of our study is that under the ACA, women with ovarian cancer are more likely to be diagnosed and receive early treatment. These gains may have a long-term impact on survival, health, and well-being for women diagnosed with ovarian cancer,” Dr Smith said.

Speaking at the press conference, ASCO Expert Merry Jennifer Mark­ham, MD, FACP, Associate Director for Medical Affairs, University of Florida Health Cancer Center, Gainesville, said, “This study shows that access to healthcare can eliminate disparities and increase access to earlier diagnosis and earlier treatment, and ultimately improve long-term outcomes for patients with ovarian cancer.”


  1. Adamson BJS, Cohen AB, Estevez M, et al. Affordable Care Act (ACA) Medicaid expansion impact on racial disparities in time to cancer treatment. J Clin Oncol. 2019;37(suppl):Abstract LBA1.
  2. Smith AJ, Nickels A. Impact of the Affordable Care Act on early-stage diagnosis and treatment for women with ovarian cancer. J Clin Oncol. 2019;37(suppl):Abstract LBA5563.
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