Impact of the Affordable Care Act (ACA) on Colorectal Cancer Outcomes among Medicare Beneficiaries: The Role of Race/Ethnicity and Community-Level Social Risk

• Main Author: Mbah, Olive M
• Format: Dissertation
• Language: English
• Published: ProQuest Dissertations & Theses 01-01-2022
• Subjects: Public health; Public policy
• ISBN: 9798438798873

Colorectal cancer (CRC) diagnosis and treatment have improved significantly over time in the US, but racial/ethnic and geographic-level inequities persist. Persons of color are more likely than Whites to experience worse CRC morbidity and mortality. Healthcare system barriers to cancer care, including patient experiences within the healthcare system, disproportionately affect persons of color and may contribute to inequities. The Affordable Care Act (ACA) included several provisions aimed at improving access to preventive care and mitigating inequities, including the elimination of cost-sharing for preventive services starting in 2011. The objective of this dissertation is to assess the contribution of patient experiences with care to CRC screening inequities (aim 1) and evaluate the impact of the ACA on inequities in CRC screening (aim 2) and rates of early-stage CRC diagnosis (aim 3) among Medicare beneficiaries. In aim 1, we used 2005-2017 Medicare Current Beneficiary Survey (MCBS) data to assess the contribution of five dimensions of patient experiences with care to CRC screening inequities through logit modeling with effect decomposition. In aim 2, we employed a difference-in-difference analysis with propensity score weights to assess the impact of the ACA on racial/ethnic and community-level inequities in CRC screening, using MCBS data linked to the Area Health Resource File (AHRF). For aim 3, we used an interrupted time series (ITS) analysis to assess the impact of the ACA on racial/ethnic and community-level inequities in rates of early-stage CRC diagnosis using the Surveillance, Epidemiology and End Results (SEER) program of cancer registries, linked to Medicare claims (SEER-Medicare) and AHRF data. We found that inequities in patient experiences with care contributed to lower screening rates among Black and Hispanic/Latinx Medicare beneficiaries compared with their White counterparts. Among beneficiaries with no supplemental insurance, the ACA had no effect on overall CRC screening rates or on racial/ethnic and community-level inequities in CRC screening. The ACA only minimally reduced the Black-White difference in rates of early-stage CRC diagnosis. These findings suggest that beneficiaries of color continue to experience worse access to CRC care and additional policy interventions are needed to address these inequitable outcomes. This work highlights potential interventions that may help address these longstanding inequities.