Guest commentary: Identifying barriers to life-saving health care

Gerald Fletcher

In this guest commentary, Gerald Fletcher, MD, MBA, from Harlem Hospital Center, discusses the data he presented during Digestive Disease Week 2019. His study, titled “Disparities in colorectal cancer screening: The effect of ACA Medicaid expansion on minorities and low-income populations,” highlights areas of need within these populations regarding CRC screening.

Colorectal cancer (CRC) is the second-leading cause of cancer deaths in the U.S. and is expected to account for more than 51,000 deaths this year alone. The disease is largely preventable with regular screening and in some cases is treatable if detected early. While inroads have been made across the country to increase screening rates, the fact remains that 1 in 3 people are not up to date on this crucial means of prevention. This is a tragic statistic because an estimated 60% of CRC deaths could be prevented with screening.

So why aren’t more Americans getting screened and what can we do to increase these numbers?

We see the biggest barriers to screening among low-income populations and minorities, especially those without a primary care physician to give them proper referrals. This is particularly important because these populations experience a higher rate of CRC incidence and mortality.

That’s why my colleagues and I at Harlem Hospital Center in New York wanted to look at how the Affordable Care Act (ACA) influenced access and use of CRC screening in states that chose to expand Medicaid starting in 2014, and were eager to present our findings at Digestive Disease Week 2019.

We compared the data of 893,004 patients who self-reported that they had undergone at least one kind of CRC screening test in Medicaid expansion states, compared with non-expansion states. The tests included fecal occult blood test, sigmoidoscopy or colonoscopy. The data were pulled from the comprehensive, 50-state Behavioral Risk Factor Surveillance System (BFRSS) from 2011 to 2016.

Our research found that a greater proportion of people completed CRC screening in states that expanded Medicaid. In fact, Medicaid expansion led to a nearly 3% overall increase in self-reported use of CRC screening tests by adults aged between 50 and 64 years, with colonoscopy representing the largest increase. Among patients who were identified as undergoing at least one kind of CRC screening modality, 62% were in expansion states and 38% were in non-expansion states.

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This increase in screening was consistent across all income groups considered in our study, but not all ethnic groups. We were surprised to find that only Hispanics and non-Hispanic whites reported an increase in screening, compared with non-Hispanic blacks, multiracial ethnic groups and others.

These findings have important implications: although the ACA increased access to CRC screening, not everyone who benefitted from increased access took advantage of this vital prevention tool. This shows us that while Medicaid expansion and access to health insurance are very important factors in developing policy, they are not the only factors that should be considered when designing a health system and encouraging utilization. We must also account for differences in people’s health beliefs and in how they make decisions about their health care.

For me, our findings illustrate the pressing need for more research to identify the best specific methods and motivators to ensure that the largest number of people have access to and are taking advantage of increased opportunities for potentially life-saving care.

Reference: Fletcher G, et al. Abstract 839. Presented at: Digestive Disease Week; May 18-21, 2019; San Diego.

Disclosures: Fletcher reports no relevant financial disclosures.