The Impact of Public Policy on Cancer Disparities

Jan 14, 2022

By Manuel R. Espinoza Gutarra, MD

The U.S. Centers for Disease Control and Prevention (CDC) define Health in All Policies as a collaborative approach that integrates and articulates health considerations into policymaking across sectors to improve the health of communities1; this definition was based on the World Health Organization Helsinki Statement of 2013 which recognized the importance of social determinants of health in public health policy.2 This declaration formalizes what had been noted for many years: that government action and legislation in sectors as wide as education, transportation, housing, and labor, to name a few, have an impact on population health and must be considered in their planning and execution stages. Compared with other high-income nations, the United States has been relatively slow in adopting this framework and attempts at health care reform have had mixed results.
The Affordable Care Act (ACA), while essentially a health care-directed legislation, has had a tremendous impact on cancer care and in reducing cancer disparities.3 The uneven uptake of the ACA constitutes the largest natural experiment in public health in the United States. A positive impact has been observed in ACA-compliant states, with decreased rates of delay in care,4 improvement in insurance rates, and uptake in screening5; however, leaving implementation to state governments has meant that U.S. citizens in 15 states have been deprived of these gains. The ACA’s own shortcomings have made it less effective in combating health care expenditure growth.
Another data point highlighting the limitations of the ACA as an all-encompassing health care bill was the fact that in 2018 the United States noted an overall decrease in life expectancy, which was mainly driven by an increase in excess deaths among working-age adults, particularly from drug overdose and suicide.7 This loss of life has hit disadvantaged communities the hardest, with working class and rural populations bearing the brunt of the damage.8 This tragic event has not been documented outside of active wartime since the collapse of the Soviet Union.9 
Climate change constitutes another health policy-related challenge that has not been appropriately addressed, with once-in-a-lifetime weather events becoming commonplace. These events result in a further deterioration of air quality, UV exposure, chemical pollution, and food supply disruption, which could result in setbacks in cancer control and survival.10 Higher rates of air pollution have been observed in communities of color, which notes their proximity to carbon-emitting industries11 and also makes them considerably less equipped to deal with the challenges posed by climate changes.12
Finally, the inadequate response of the United States to the COVID-19 pandemic has already resulted in over 700,000 deaths13 and a 19.2% contraction in the U.S. economy.14 Black and Latino people have experienced loss of life severe enough to note a reduction in life expectancy.15 These outcomes will have ripple effects which will be felt for years to come, as some household incomes drop and poverty rates increase for already disadvantaged groups. These economic effects are likely to deepen as federal housing and unemployment protections wane.
As oncologists we have strived to improve cancer outcomes and ameliorate the disproportionate burden cancer places on disenfranchised communities. Given the above-mentioned facts, I am afraid that the progress realized by the diligent work of patients, caregivers, and health care workers in reducing cancer disparities might be reversed. Cancer care is highly technical, multidisciplinary, and protracted, and as such, our patients might find themselves in the unfortunate position of being canaries in the mine: the first casualties of the post-pandemic global recession and other long-standing unaddressed sociological ills.
It is in this context that we must acknowledge the pitfalls of prior attempts at mending public health and devise new strategies to tackle this ever-worsening problem. Sweeping federal policies coupled with competent implementation by state and local governments are sorely needed to turn this around. While this might seem to be an unrealistic goal in a very politically divided country, we should encourage new forms of politics to emerge, and new stakeholders—including our entire community of cancer care professionals—should increase advocacy through traditional and nontraditional means to see this through. 
The alternative is to ignore this social neoplasm; and we all know how that ends.
Dr. Espinoza Gutarra is a hematology-oncology fellow at Indiana University. He is a member of the ASCO Trainee and Early Career Council.
  1. Centers for Disease Control and Prevention. Health in All Policies. Reviewed Jun 9, 2016. Available at: Accessed Oct 10, 2021.
  2. The Helsinki Statement on Health in All Policies. Health Promot Int. 2014;29 Suppl 1:i17-8.
  3. Choi SK, Adams SA, Eberth JM, et al. Medicaid Coverage Expansion and Implications for Cancer Disparities. Am J Public Health. 2015;105 Suppl 5(Suppl 5):S706-12.
  4. Wharam JF, Zhang F, Wallace J, et al. Vulnerable And Less Vulnerable Women In High-Deductible Health Plans Experienced Delayed Breast Cancer Care. Health Aff (Millwood). 2019;38:408-15.
  5. Jemal A, Lin CC, Davidoff AJ, et al. Changes in Insurance Coverage and Stage at Diagnosis Among Nonelderly Patients With Cancer After the Affordable Care Act. J Clin Oncol. 2017;35:3906-15.
  6. Antos JR, Capretta JC. The ACA: Trillions? Yes. A Revolution? No. Health Affairs. Apr 10, 2020. Available at: Accessed Oct 10, 2021.
  7. Venkataramani AS, O’Brien R, Tsai AC. Declining Life Expectancy in the United States: The Need for Social Policy as Health Policy. JAMA. 2021;325:621-2.
  8. Venkataramani AS, O’Brien R, Whitehorn GL, et al. Economic influences on population health in the United States: Toward policymaking driven by data and evidence. PLoS Med. 2020;17:e1003319.
  9. Klenk J, Keil U, Jaensch A, et al. Changes in life expectancy 1950-2010: contributions from age- and disease-specific mortality in selected countries. Popul Health Metr. 2016;14:20.
  10. Hiatt RA, Beyeler N. Cancer and climate change. Lancet Oncol. 2020;21:e519-e527.
  11. Tessum CW, Paolella DA, Chambliss SE, et al. PM2.5 polluters disproportionately and systemically affect people of color in the United States. Sci Adv. 2021;7:eabf4491.
  12. Aja AA, Beesing G, Bustillo D, et al. The Color of Wealth in Miami. A Joint Publication of The Kirwan Institute for the Study of Race and Ethnicity at The Ohio State University, the Samuel DuBois Cook Center on Social Equity at Duke University, and the Insight Center for Community Economic Development. Feb 2019. Available at: Accessed Oct 26, 2021.
  13. Johns Hopkins University & Medicine. Coronavirus Resource Center. Available at: Accessed Oct 10, 2021.
  14. US Bureau of Economic Analysis. Gross Domestic Product, Second Quarter 2021 (Advance Estimate) and Annual Update. Jul 29, 2021. Available at: Accessed Oct 10, 2021.
  15. Andrasfay T, Goldman N. Reductions in 2020 US life expectancy due to COVID-19 and the disproportionate impact on the Black and Latino populations. Proc Natl Acad Sci U S A. 2021;118:e2014746118.

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