Synergistic Improvements in Cancer Care: The ACA Plus Existing Safety Net Systems

Introduction: Prior studies have shown the Affordable Care Act (ACA) has improved access for Head and Neck Cancer (HNC) patients. It is unknown whether the ACA has impacted HNC care in safety net hospitals with pre-existing systems for access to care, justifying additional resource allocations alongside Medicaid expansion.

Methods: 1428 HNC patients were identified through retrospective chart review, diagnosed at our tertiary care hospital with pre- and post-ACA safety net mechanisms, from 1996 to 2019. Patient demographics, tumor stage, treatment, follow up, and insurance status were collected. Patients were stratified by diagnosis date as before or after Affordable Care Act implementation. Group qualities were compared using Chi squared and t-tests.

Results: 396 patients were identified as pre-ACA implementation, and 1032 patients post-ACA. The diagnostic rate increased markedly from 2.5 to 9.3 diagnoses/month. Patient gender (p=0.154), English language status (p=0.166), and diagnosis age (p=0.975) did not significantly differ. Post-ACA, patients had higher rates of Medicaid and Private coverage (p < 0.0001). Patients presented more with T stages 1 or 4 (p < 0.0001) post-ACA, while N (p=0.334) and M (p=0.246) stages did not vary. All demographic groups increased in absolute numbers post-ACA except Hispanic patients (21 vs 28). On a percentage basis, there were +9% white, +1.5% Asian, -5.3% Hispanic, and -4.9% Black patients post-ACA (p < 0.0001). Compliance with tumor board recommendations (p=0.199) did not change, but there was a significant decrease in total length of follow up time (p < 0.0001), recurrence rate (p=0.001) and mortality rate (p=0.006) in the years post-ACA.

Conclusions: There is clear benefit to HNC patients with passage of the ACA, even in systems where a safety net existed previously and some at-risk aspects of HNC care had been addressed. Using our system as a reference, the present study demonstrates that improvements in access and care have been realized for HNC patients. This underscores the effectiveness of ACA, and that this can be additive to existing safety net systems to the benefit of HNC patient care.