Impact of the Affordable Care Act on Palliative and Hospice Care Utilization Among Patients with Gastrointestinal Cancers: An Interrupted Time Series Analysis.

Background: The Affordable Care Act (ACA) aimed to expand insurance coverage, improve health outcomes, and reduce costs. We assessed the impact of the ACA on hospice or palliative care utilization among patients with stage IV gastrointestinal (GI) cancer. Methods: Individuals diagnosed with stage IV GI cancer between 2007 and 2019 were identified from the Medicare database. An interrupted time series analysis (ITS) examined the impact of ACA on palliative care utilization. Entropy balancing and gamma regression were used to assess the cost implications of not utilizing palliative care. Results: Among the 26,227 stage IV GI cancer Medicare beneficiaries, approximately half (53.9%) were male. Overall, 80.5% of patients used palliative care before death. Utilization increased from 54.3% in 2007 to 84% in 2013 pre-ACA (slope: +0.009; 95% confidence interval [CI]: 0.005-0.012) and from 84.5% in Q1 2014 to 89.7% in Q4 2019 post-ACA (slope: +0.004; 95% CI: 0.0007-0.007), indicating slow progress in palliative care uptake. The ITS model demonstrated that ACA implementation did not affect palliative care utilization (slope: -0.006; 95% CI: -0.017 to +0.004). Patients from minority racial groups (odds ratio [OR]: 0.79; 95% CI: 0.74-0.86) and those in moderate (OR: 0.86; 95% CI: 0.80-0.94) and high (OR: 0.68; 95% CI: 0.62-0.74) Social Vulnerability Index (SVI) counties were less likely to use palliative care in both pre- and post-ACA eras. Palliative care use was associated with $2,633 lower total expenditure. Conclusion: ACA implementation did not improve palliative care utilization for racial minorities and high SVI groups. Targeted efforts are needed to improve access to equitable end-of-life care.