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    r> 3. Results
    Our underserved population comprised 4808 adults diagnosed with a first primary invasive solid tumor between January 1, 2008 and December 31, 2015 (Fig. 1). Table 1 summarizes the overall and in-tervention-stratified distribution of patient characteristics. Racial/ ethnic minorities comprised 51% of our underserved population. The distribution of the majority of demographic characteristics did not
    Fig. 1. Selection of underserved cancer patients using the JPS Oncology Registry.
    Fig. 3 and Supplementary Table S2 describe the changes in pre-valence of early and advanced stage diagnosis after the ACA im-plementation among all cancer patients. In particular, the prevalence of early stage diagnosis at the beginning of post-ACA K 252a decreased among underserved cancer patients, but the estimates were compatible with a substantial decrease or modest increase in early stage diagnosis (PR = 0.85; 95% CL: 0.64, 1.1). A modest increase in the prevalence of 
    early stage diagnosis was observed post-ACA period for Tarrant County and Texas overall. In addition, the prevalence of advanced-stage diag-nosis after ACA implementation decreased by 3% each quarter for Texas overall (PR = 0.97; 95% CL: 0.96, 0.98), which was largely observed for non-screen-detectable cancers. Supplementary Tables S3–S4 and Supplementary Figs. S1–S2 sum-marize our analyses exploring the effect of ACA on cancer stage stra-tified by screen-detectable status. We observed nominal or no change in level or slope for early or advanced stage diagnoses for screen-detect-able or non-screen-detectable cancers after ACA implementation except for an immediate reduction in advanced-stage screen-detectable can-cers among Tarrant County cancer patients (PR = 0.73, 95% CL: 0.46, 1.2) and an immediate reduction in the prevalence of early-stage non-screen-detectable cancers after ACA implementation among under-served cancer patients (PR = 0.83, 95% CL: 0.59, 1.2), but both esti-mates were compatible with substantial reductions or modest increases. In addition, we observed a modest reduction in the prevalence of non-screen-detectable advanced cancers over time for Texas overall (PR = 0.97, 95% CL: 0.96, 0.97).
    Table 1
    Characteristics of underserved adults diagnosed with primary solid tumors at the JPS Center for Cancer Care (2008–2015).
    Age group (years)
    c Includes American Indian, Asian, Native Hawaiian and Pacific islander.
    4. Discussion
    Our results suggest a decrease in the prevalence of uninsured pa-tients among underserved, Tarrant County, and Texas cancer patients
    over time. Nevertheless, our results do not suggest earlier cancer de-tection among underserved cancer patients following ACA im-plementation, even for screen-detectable cancers. Rather, the pre-valence of early-stage cancers modestly decreased at the beginning of the post-ACA period among underserved cancer patients, which could be the consequence of access to care affecting the detection of pre-viously undiagnosed cancers that progressed to regional stage. We ob-served a similar lack of improvement in stage at diagnosis among cancer patients in Tarrant County and Texas overall.
    Our finding of a decreased prevalence of uninsured individuals is consistent with prior studies that assessed the effect of ACA im-plementation (Blumenthal and Collins, 2014; Courtemanche et al., 2016; Frean et al., 2017; Jemal et al., 2017; Kominski et al., 2017; Sommers et al., 2015; Wherry and Miller, 2016). For example, prior studies of non-elderly individuals from national surveys reported re-ductions in the prevalence of uninsured individuals in the general po-pulation ranged between 6% and 7.9% (Frean et al., 2017; Sommers et al., 2015). The reduction of uninsured individuals in low-income populations was 5.2% to 7.4% greater for Medicaid expansion states compared with non-expansion states (Sommers et al., 2015; Wherry and Miller, 2016). Specifically for low-income cancer patients, a prior study that used the National Cancer Database reported a 6% reduction in uninsured individuals for Medicaid expansion states and only 1.4% for non-expansion states (Jemal et al., 2017). We observed a greater re-duction in uninsured prevalence than prior studies in non-expansion states, which may be attributable to a substantially higher pre-ACA prevalence of uninsured patients (64%) in our underserved cancer po-pulation. The pre-ACA prevalence of uninsured among low-income cancer patients in Medicaid non-expansion states overall was 14.7% (Jemal et al., 2017). Growth of Medicaid coverage among eligible but unenrolled individuals between late 2013 and December 2015 was only 6% in Texas, which would not explain our observed reduction in un-insured individuals (Kaiser Family Foundation, 2019).