Impact of Affordable Care Act Provisions on the Racial Makeup of Patients Enrolled at a Deep South, High-Risk Breast Cancer Clinic

Abstract

Abstract Purpose Black women are less likely to receive screening mammograms, are more likely to develop breast cancer at an earlier age, and more likely to die from breast cancer when compared to White women. Affordable Care Act (ACA) provisions decreased cost sharing for women’s preventive screening, potentially mitigating screening disparities. We examined enrollment of a high-risk screening program before and after ACA implementation stratified by race. Methods This retrospective, quasi-experimental study examined the ACA’s impact on patient demographics at a high-risk breast cancer screening clinic from 02/28/2003 to 02/28/2019. Patient demographic data were abstracted from electronic medical records and descriptively compared in the pre- and post-ACA time periods. Interrupted time series (ITS) analysis using Poisson regression assessed yearly clinic enrollment rates by race using incidence rate ratios (IRR) and 95% confidence intervals (CI). Results Two thousand seven hundred and sixty-seven patients enrolled in the clinic. On average, patients were 46 years old (SD, ± 12), 82% were commercially insured, and 8% lived in a highly disadvantaged neighborhood. In ITS models accounting for trends over time, prior to ACA implementation, White patient enrollment was stable (IRR 1.01, 95% CI 1.00–1.02) while Black patient enrollment increased at 13% per year (IRR 1.13, 95% CI 1.05–1.22). Compared to the pre-ACA enrollment period, the post-ACA enrollment rate remained unchanged for White patients (IRR 0.99, 95% CI 0.97–1.01) but decreased by 17% per year for Black patients (IRR 0.83, 95% CI 0.74–0.92). Conclusion Black patient enrollment decreased at a high-risk breast cancer screening clinic post-ACA compared to the pre-ACA period, indicating a need to identify factors contributing to racial disparities in clinic enrollment.