Too little, too late to save Obamacare?

CHICAGO — As the nation prepares to once again litigate the future of the Affordable Care Act, a pair of studies reported here provide evidence that access to healthcare can lead to earlier detection of ovarian cancer and — in some states — the elimination of racial disparities in cancer treatment.

Those findings were not just reported at the American College of Clinical Oncology meeting here — they were put in a spotlight normally reserved for only the “hottest” of clinical trial findings included in the plenary session and featured at an ASCO press conference.

Asked if ASCO was signaling support of the ACA or perhaps sending a message to Washington, where the current administration is supporting a ruling by a Texas judge declaring the ACA unconstitutional, ASCO’s chief medical officer Richard L. Schilsky, MD, demurred: “Look, access is important and ASCO believes that every patient deserves access to cancer care, but ASCO doesn’t take a position on the ACA. It has aspects we like, and others that we’ve fought,” he said.

“One thing that we are very firm about: cancer should never be considered a pre-existing condition.”

ASCO’s main interest is in data and evidence, “and these studies are providing evidence that increased access is beneficial,” he added.

The evidence in both studies comes from analysis of data from the National Cancer Database. In one study, Anna Jo Smith, MD, MPH, and Amanda Nickles Fader, MD, from Johns Hopkins, sought to determine the effect, if any, of the ACA on early stage diagnosis of ovarian cancer. They looked at treatment for ovarian cancer for women 21-64 over a 10-year period: 5 years before the ACA became law and 5 years after. They used ovarian cancer treatment for women age 65 or older (Medicare patients) during the same period and adjusted both findings for “race, living in a rural area, income, education, Charleston co-morbidity score, distance traveled for care, Census region, and care at an academic center.”

They used “a ‘difference in differences (DD)’ approach for the analysis that compares changes over time between two groups” and found that, compared to controls, in younger women “there was a relative gain of 1.7% in early-stage diagnosis (defined as stage 1 or 2) of ovarian cancer. There was also a relative improvement of 1.6% in women being treated within 30 days of diagnosis for those age 21 to 64 as compared with women 65 and older.”

Smith, who presented the findings “virtually” from her office in Baltimore, said there was a larger gain for women who received “public insurance post-ACA”: they had a relative gain of 2.5% in the rate of early diagnosis and timely treatment.

Those small differences, Smith said, translated into about 400 women receiving early diagnosis when their cancer was at a treatable stage.

In the second study, the researchers looked at the impact of Medicaid expansion on racial disparities in time to cancer treatment. Amy Davidoff, PhD, who discussed the findings at an ASCO press conference, explained that they used data from electronic health records from January 2011 through January 2019 to identify 30,386 patients diagnosed with advanced or metastatic cancer. Of those 18,678 patients lived in states that have not expanded Medicaid programs and the rest lived in states with Medicaid expansion.

Initially, the researchers set out to compare global differences in cancer treatment before and after ACA, but they found no significant differences. They then decided to analyze the data seeking a signal for racial disparity, and they found it: in states where Medicaid expansion has not occurred, there is a 4.8% difference in the rate of timely treatment, with blacks being less likely to receive timely cancer treatment. “But in states that have expanded Medicaid, that difference disappears.”

Taken together, the findings support ASCO’s position that access improves cancer outcomes, said Schilsky, and both fit nicely into ASCOsPrinciples for Patient-Centered Healthcare Reform“, which includes this first principle: “All Americans should have access to affordable and sufficient healthcare coverage regardless of their income or health status. To ensure protected access, the current ban on pre-existing condition limitations, elimination of annual and lifetime coverage caps, and maintenance of guaranteed renewability should be preserved.”

Finally, returning to the issue of “timing,” a member of ASCO’s communication committee, William Dale, MD, PhD, of City Hope in Duarte, California, had this to say when he was asked “why ACA, why now”? “It was generally agreed that this was the right time to highlight the impact of ACA because we had the studies and enough time has passed so that it is possible to measure the effect, so everyone in the room agreed that we needed to highlight these results.”

Dale added that a good part of the impetus, a push even, came from ASCO’s president Monica M. Bertagnolli, MD, who “has made patient access the focus of her presidency.” No ulterior motives, just a basic commitment by ASCO’s leader, he said.

Yet, when BreakingMED asked the panel at the press conference if the studies were highlighted at this time precisely because the ACA is again at risk, the reaction was not a swift denial but rather smiles and muffled laughs.



The Medicaid expansion study was funded by Flatiron Health Inc.

Davidoff disclosed consulting or advisory Role with Amgen, (Immediate Family Member) with Celgene and Abbvie, Other Relationship with PhRMA Foundation, Honoraria (Immediate Family Member) with Celgene, Kyowa Hakko Kirin, Jazz Pharmaceuticals and Tolero Pharmaceuticals, Research Funding (Institutional) from Boehringer Ingelheim and Celgene.

Dale had no disclosures.

Diefenbach disclosed Stock ownership in Gilead Sciences, consulting for Bayer, Bristol-Myers Squibb, Genentech/Roche. Janssen, Merck, Seattle Genetics, and research funding from Bristol-Myers Squibb (Inst), Genentech (Inst), Incyte (Inst), Janssen (Inst), LAM Therapeutics (Inst), MEI Pharma (Inst), Merck (Inst), Millennium (Inst), Roche/Genentech (Inst), and Seattle Genetics (Inst).

The ovarian cancer study was funded by Johns Hopkins Department of Gynecology and Obstetrics Kelly Society Grant. The authors had nothing to disclose.


Adamson B, et al “Affordable Care Act Medicaid expansion impact on racial disparities in time to cancer treatment” ASCO 2019; Abstract LBA 1.

Smith AJ, Fader AN “Effects of the Affordable Care Act on women with ovarian cancer” ASCO 2019; Abstract BBA5563.


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