ACA Increased Cancer Screening…Barely

The ACA’s Medicaid expansion theoretically expands access to cancer screening to vulnerable populations with the intent to gradually decrease the financial burden associated with cancer. As these evidence-based preventive screening tools are now covered by Medicaid, vulnerable populations that are disproportionately diagnosed with advanced cancer would have earlier opportunities for diagnosis. Recent research assesses the impact of the Medicaid expansion on the delivery of pap smears for cervical cancer, mammography for breast cancer, and colonoscopy for colorectal cancer amongst covered adults without dependent children.

For colorectal cancer screening and cervical cancer screening, adjusted screening rates were significantly higher in the ACA expansion group during the post-expansion period (OR 1.04 and 1.12, respectively). Results were not significant for breast cancer screening.

While the study demonstrated a positive correlation between coverage under Medicaid expansion and increased rates of cancer screening, its results do not reflect the dramatic impact that some would expect. It is notable that Americans in expansion states had higher levels of education and smaller proportions of Black non-Hispanic persons. Education and race may serve as confounding factors, as these population characteristics are generally associated with better health outcomes. Expansion states also had higher screening rates both before and after expansion, suggesting that the baseline increased access to care and health literacy in these states could also explain the attenuated difference in screening rates after expansion.  

It is also worth acknowledging an assumption with the hypothesis that financial coverage of prevention services is single-handedly sufficient to increase screening utilization. To take part in preventive measures, patients must have the opportunity to be offered and educated on the importance of the screenings and must have the inherent trust in the organizations that recommend the screenings. Without assuring appropriate primary care relationships for Medicaid patients, there is little reason to assume that they would have increased uptake in cancer screenings. 

Further research is warranted to analyze the holistic impact of Medicaid expansion on the coverage and delivery of cancer screening, its relationship to primary care utilization, and ultimately the actual cancer burden on those newly-covered.

Abstract

BACKGROUND: We tested whether Medicaid expansion under the Affordable care Act was associated with increased screening for cervical, breast, and colorectal cancer among low-income adults.

METHODS: We analyzed Behavioral Risk Factor Surveillance System data, identifying 2012 as preexpansion and 2016 as postexpansion (2014 was treated as a wash-out, and 2013 and 2015 had missing screening data from most states). States (including District of Columbia) either expanded Medicaid in 2014 (n=28) or not (n=18); five states that expanded after 2014 were excluded. Participants included low-income adults aged 18-64 without dependent children. A difference-in-difference approach tested whether expansion was significantly associated with screening, controlling for time, state effects, age, sex, race/ethnicity, education, and urban/rural population. For comparison, we also conducted analyses among the low-income Medicare (aged 65 and above) population, and a higher income population.

RESULTS: There was a significant expansion effect for women aged 18-64 for cervical cancer screening (N=29,059; odds ratio, 1.04; 95% confidence interval, 1.01-1.08), and for adults 50-64 for colorectal cancer screening (N=32,290; odds ratio, 1.12; 95% confidence interval, 1.03-1.22). Effects for mammography for women aged 40-64, or aged 50-64, were not significant. As expected, there were no significant improvements associated with expansion among the Medicare population, or among a population ineligible due to higher income.

CONCLUSIONS: Medicaid expansion under the Affordable Care Act was associated with increased screening for cervical and colorectal cancer for low-income adults. It will be important to monitor possible adverse cancer outcomes in nonexpansion states among vulnerable populations over time.

PMID: 30199428 

Hendryx, M and Luo, J. Medical Care. 2018; 56 (11): 944-949.