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ACA leads to increase in screening mammography, not colonoscopy
An uptake in the number of mammography screenings occurred among various economic subgroups after the Affordable Care Act was implemented in 2011, according to new findings published in Cancer.
However, the screening rate for colonoscopy has remained the same.
“The main findings of the study were that although in the pre-Affordable Care Act era there were disparities in screening, they narrowed only for mammography and not colonoscopy,” Gregory S. Cooper, MD, program director of gastroenterology at University Hospitals Cleveland Medical Center, and co-program leader for cancer prevention and control at Case Comprehensive Cancer Center, told HemOnc Today. “As a result of this study, we would recommend looking at other patient groups such as privately insured and also specifically at minority populations. It would also be informative to survey patients to determine to what degree out-of-pocket expenses hindered their use of these procedures.”
One of the goals of the Affordable Care Act (ACA) was to eliminate out-of-pocket expenditures for preventative services — including mammography and colonoscopy — approved by the U.S. Preventive Services Task Force. The goal was to help eliminate socioeconomic disparities in cancer incidence and the stage of cancer at presentation.
“The ACA, among other features, removed out-of-pocket expenses for approved preventive services, and this may have served as a barrier to cancer screening in socioeconomically disadvantaged individuals,” Cooper said. “If so, then the gap in screening between socioeconomic groups should narrow following the ACA.”
Using random samples of Medicare beneficiaries aged 70 years and older, Cooper and colleagues conducted mammography and colonoscopy analyses to determine whether the absence of out-of-pocket expenditures impacted the rate of these screenings over time. The researchers also estimated ORs for the effects of median county-level income and education quartiles before and after ACA implementation using data from the 2010 U.S. Census.
For the mammography analysis, researchers evaluated data from 862,267 women (mean age, 79.7 ± 6.9 years) who had not undergone mammography in the previous 2 years. More than 16% of women had increased risk for breast cancer and 57.2% had undergone one or more mammograms within the previous 5 years.
Compared with women in the highest quartiles, the OR for screening among women in the lowest income quartile increased from 0.87 (95% CI, 0.86-0.88) pre-ACA to 0.94 (95% CI, 0.93-0.95) post-ACA, and the OR for screening among women in the lowest education quartile increased from 0.76 (95% CI, 0.75-0.77) to 0.86 (95% CI, 0.85-0.87).
These increases occurred across all socioeconomic quartiles.
For the colonoscopy analysis, researchers evaluated data from 326,503 men and women aged 70 years and older (mean age, 77.1 ± 6 .1 years) who did not undergo colonoscopy within 5 years.
Compared with the highest quartiles, the OR for screening among individuals in the highest income quartile was 0.95 (95% CI, 0.91-0.97) pre-ACA and 0.92 (95% CI, 0.90-0.95) post-ACA. For education, the ORs for screening were 0.96 (95% CI, 0.93-1.03) pre-ACA and 1 (95% CI, 0.97-1.03) post-ACA.
Overall, ORs that compared colonoscopy rates before and after the ACA showed a small decrease in uptake.
The researchers noted that screening mammography and colonoscopy were covered under Medicare before ACA implementation; however, beneficiaries were responsible for paying a 20% coinsurance for mammography and 25% for colonoscopy. Patients also were responsible for deductibles in some cases. Both coinsurance and deductibles were waived for screening examinations post-ACA, but beneficiaries are still responsible for coinsurance for diagnostic indications.
“Financial barriers do exist but reduction or elimination may not be the only solution to increasing uptake, especially for procedures that are more involved, such as colonoscopy,” Cooper said.
“The future of the ACA is uncertain and if it is dismantled, it is not known if benefits such as preventive care will be maintained,” he added. “Our study does support, at least for mammography, the value of eliminating financial barriers to care.” – by Melinda Stevens
Disclosures: The researchers report no relevant financial disclosures.