Background: African American patients with bladder cancer have inferior outcomes compared to non-Hispanic White (White) patients. We hypothesize that access to health care is a primary determinant of this disparity. We compared outcomes by race for patients with bladder cancer receiving care within the predominant hybrid-payer healthcare model of the United States captured in the Surveillance, Epidemiology, and End Results (SEER) database to those receiving care within the equal-access model of the Veterans' Health Administration (VHA).

Methods: African American and White patients diagnosed with bladder cancer were identified in SEER and VHA. Stage at presentation, bladder cancer-specific mortality (BCM), and overall survival (OS) were compared by race within each healthcare system.

Results: SEER cohort included 122,449 patients (93.7% White, 6.3% African American). VHA cohort included 36,322 patients (91.0% White, 9.0% African American). In both cohorts, African American patients were more likely to present with muscle-invasive disease and metastases but the differences between races were statistically significantly smaller in VHA. In SEER multivariable models, African American patients had worse BCM (hazard ratio [HR] = 1.22, 95% confidence interval [CI] = 1.15-1.29) and OS (HR = 1.26, 95% CI = 1.20-1.31). In contrast within VHA, African American patients had similar BCM (HR = 0.97, 95% CI = 0.88-1.07) and OS (HR = 0.99, 95% CI = 0.93-1.05).

Conclusion: In this study of contrasting healthcare models, receiving medical care in an equal-access system was associated with reduced differences in stage at presentation and eliminated disparities in survival outcomes for African American patients with bladder cancer. Our findings highlight the importance of reducing financial barriers to care to notably improve health equity and oncologic outcomes for African American patients.