Health

Cancer Screening Improved With ACA’s Medicaid Expansion

After the introduction of the Affordable Care Act (ACA), screening for colorectal cancer (CRC) and breast cancer increased in low-income adults 50 to 64 years of age in states that expanded Medicaid coverage, researchers found.

The increases were largest, and significantly greater, for recent CRC screening in states with very early expansion compared with non-expansion states, suggesting that large-scale improvements in cancer screening after expanded insurance coverage may take several years, reported Stacey A. Fedewa, PhD, of the American Cancer Society in Atlanta, and colleagues in the American Journal of Preventive Medicine.

In the post-ACA period, absolute up-to-date CRC screening increases occurred among low-income adults in 2016 versus 2012 according to the variable of Medicaid expansion:

  • By 8.8% in states with very early expansion of coverage
  • By 2.9% in those with early expansion
  • By 2.4% in late-expansion states
  • By 3.8% in non-expansion states

In addition, past 2-year CRC screening increased by 8.0% in very early states and 2.8% in non-expansion states, with an adjusted difference-in-differences of 4.9% relative to non-expansion states (P=0.041).

During the same period, up-to-date breast cancer screening increased among low-income women by 5.1%, 4.9%, and 3.7% in very early, early, and non-expansion states, respectively. Late-expansion states saw a drop of 1.8%.

The ACA mandated first-dollar coverage of recommended screening under private as well as public insurance.

“In addition, by 2016, socioeconomic disparities in CRC and breast cancer screening narrowed more rapidly in Medicaid expansion states than in non-expansion states, though inequalities persist in all states,” Fedewa’s group wrote.

The researchers noted from past research that health insurance is a strong predictor of cancer screening, and uninsured and lower-income individuals are more likely to be diagnosed at a late stage and die from screening-detectable cancers.

The study used 2012, 2014, and 2016 data from the Behavioral Risk Factor Surveillance System (BRFSS), the annual telephone survey overseen by the CDC. Up-to-date and past 2-year screening prevalences for CRC (n=95,400) and breast cancer (n=43,279) were computed among low-income respondents for each of the 3 years.

Individuals at less than 138% of the federal poverty level (FPL) were eligible for Medicaid coverage in expansion states; the researchers used a household income of less than $25,000 as a proxy for that threshold, with sensitivity and specificity of 90% or more.

According to the timing of Medicaid expansion the states of BRFSS respondents were grouped as:

  • Very early: six states expanding March 1, 2010 to April 14, 2011
  • Early: 21 states expanding Jan. 1, 2014 to Aug. 15, 2014
  • Late: five states expanding Jan. 1, 2015 to July 1, 2016
  • Non-expansion: 19 states

The results parallel those of a 2018 study reporting increased cervical and CRC screening for low-income adults after Medicaid expansion, but, Fedewa and colleagues indicated, they also show that the increase was related to Medicaid expansion by year 2011 in six states.

Other research has reported a positive impact of the ACA on screening rates.

The authors noted that the lack of immediate increases in CRC screening following Medicaid expansion may reflect the lag time between gaining insurance and completing the multistep process leading to actual screening. “Furthermore, once people obtain insurance, there is pent-up demand to address more-immediate health conditions or symptoms,” they wrote.

Despite improvements, they added, inequalities in screening remain substantial, even in states with expanded Medicaid. In 2016, only about half of low-income adults were up to date with CRC screening compared with about two thirds of their higher-incomes counterparts. “Provider recommendation is a strong facilitator of cancer screening, and there may be missed opportunities within healthcare encounters to recommend screening in this population,” Fedewa and colleagues wrote, referring to a 2015 study that found primary-care providers ordered fewer preventive services for women on Medicaid than for their privately insured counterparts.

Study limitations included the self-reporting of screening data, which may have introduced recall bias, and survey response rates of approximately 50% that may have introduced bias, although analyses were weighted to account for non-response. In addition, unmeasured confounders such as local programs for improving screening rates may not have been captured in adjusted models.

Furthermore, major changes in BRFSS sampling precluded direct comparison before and after 2011, and data were therefore not available for pre-expansion in very early states. Nor did the study capture data on changes in insurance type — for example, from private plans to Medicaid — and a previously insured individual could have undergone colonoscopy before Medicaid coverage.

Benjamin D. Sommers, MD, PhD, of the Harvard T.H. Chan School of Public Health in Boston, also cited the absence of pre-2010, pre-ACA data, and the use of a rough measure of respondents’ incomes.

“But the general idea that giving people health insurance leads to increased preventive care is well established by previous studies, so we’d expect to see something similar here,” said Sommers, who was not involved in the study.

He pointed out that cost to patients is only one of the barriers to care in the U.S., with factors such as transportation barriers and time needed for appointments also influencing tests. “This may be particularly relevant for a colonoscopy, which takes significant time both for the preparation and the test itself and recovery afterwards, unlike, say, a mammogram which is a pretty straightforward and short test,” he added.

Sommers said there are other challenges with information and patient education. For example, a cancer screening test is by definition a test for a condition that is not yet causing symptoms. “So it can be hard sometimes to motivate people to get these tests done, even if the test if covered, as under the ACA,” Sommers said.

Fedewa and co-authors disclosed no relevant relationships with industry.

The American Cancer Society Surveillance and Health Services Research Program is supported by a grant from Merck.

2019-05-22T13:00:00-0400


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