Our results demonstrate that, in the five-year period following ACA implementation, Medicaid expansion and implementation of cost-sharing preventive services for average risk women in the U.S., yearly rates of Black and White patient enrollment remained stable. However, in the context of the effect of ACA implementation on the rate of patient enrollment relative to the pre-ACA period, our results showed that rates of White patient enrollment remained consistent throughout pre and post-ACA implementation periods. Rates of Black patient enrollment, however, decreased in the post-ACA time period relative to the pre-ACA time period.
Further research must be done to elucidate the additional factors associated with the significant decrease in Black patient enrollment following implementation of expanded women’s preventive services by the ACA compared to the pre-ACA implementation period. For example, publicization of the UABPC’s existence and its referral process may be optimized to improve access. Knowledge of the UABPC is largely spread through internal providers within the UAB healthcare system by word of mouth rather than a standardized referral process. Providers external to the UAB system are less likely to be aware of the clinic thus less likely to refer patients. Additionally, most patients are self-referrals and are aware of the clinic via spoken communication. This is another opportunity to examine racial disparities.
ACA implementation and Medicaid expansion was enacted as a path to increase the percentage of the insured in the U.S., especially those in low-income communities. Historically, more African Americans live in poverty or at a lower socioeconomic status when compared to their White counterparts [13]. Although the ACA was targeted at this community and other communities at lower socioeconomic status, we noted a decrease in the enrollment of Black patients during the post-expansion period. In exploring the possible reasons for this downward trend in enrollment, it is possible that the historical distrust of the healthcare system within the Black community could have adversely influenced Black patient enrollment in the UABPC. This pervasive and warranted distrust is vested in the historical mistreatment and abuse of African Americans by the U.S. healthcare system, with levels of mistrust higher amongst those African Americans that are known descendants of the enslaved [14]. In a community that has already been marginalized by the U.S. healthcare system, it is possible that patients of color who had a dissatisfying experience within the UABPC could have discouraged their community members from seeking further care through the clinic. Furthermore, in certain minority communities, health concerns and hardships are sometimes considered culturally taboo, and therefore it can be difficult to establish a thorough history and encourage self-advocacy in seeking preventive care through the UABPC [15]. Alternatively, it is possible that during the post-expansion period, there was a decrease in the number of providers within and outside the UAB system that served a greater number of African American patients. It can be equally challenging for a patient who is already distrustful of the healthcare system to reestablish care with a provider with whom they do not have an established history. Because of these potential environmental shifts that can contribute to patient care and could cause a downtrend in UABPC patient enrollment, further investigation is warranted to understand the referral process to the UABPC and communities it predominantly serves.
Within the community, primary care providers such as family medicine physicians and Obstetrician Gynecologists primarily conduct breast cancer risk assessments to estimate women’s lifetime risk for breast cancer based on a variety of modifiable and non-modifiable risk factors [16]. The variety of available risk assessment tools can also lead to their underutilization, resulting in patients’ who are unsure of their own risk status for breast cancer [17]. Community physicians may opt to manage these patients themselves rather than referring to a breast cancer specialist in the absence of palpable mass or breast cancer diagnosis. Additionally, statewide, physicians in the community may not be aware of the existence of the UABPC, and therefore not refer their patients.
Uninsurance or underinsurance is associated with other social determinants of health such as belonging to a minority racial group, having a lower educational status, or earning a lower wage [18, 19]. These characteristics predispose patients to a decreased potential of upward social mobility, influencing their overall socioeconomic status and directly obstructing access to preventive care or appropriate screening for their high risk status. Although non-Medicaid expansion states like Alabama did not receive additional funding to expand women’s preventive services, many non-Medicaid expansion states still experienced an increase in insurance utilization following Medicaid-expansion, likely due to the increased awareness of insurance accessibility and importance of preventive healthcare initiatives popularized by the ACA [18]. In light of the central drive for Medicaid-expansion, if Alabama were to expand Medicaid, its citizens could experience increased insurance access and access to breast cancer screening modalities, incur lower incidences of late-stage breast cancer diagnoses, and become a more health-informed population [20].
A notable limitation in this study was that the initial provisions within the ACA decreased cost sharing for women’s preventive services for women at average risk for developing breast cancer, rather than high-risk. Despite this, we felt trends reflected in the average risk community, such as increased mammography screening, would be mirrored in the high-risk community. In addition to this limitation, we acknowledge that further investigation into the clinic referral patterns of the UABPC may yield a better understanding of the decreased enrollment of Black patients in the UABPC during the post-ACA period. Additionally, our study reflects the trends of enrollment for those patients who were able to access the UABPC either through self or physician referral. Therefore, our trends may not be incorporating those patients that are the most under-represented which would suggest a more notable inequity in access to high-risk preventive services in the post-expansion period.