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Elimination of cost-sharing under ACA increases access to mammography
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The rate of mammography increased six percentage points among older women for whom it is recommended following the elimination of screening cost-sharing under the Affordable Care Act, according to study results published in The New England Journal of Medicine.
“Out-of-pocket costs can be a potent barrier to receiving recommended preventive care,” Amal N. Trivedi, MD, MPH, associate professor of health services, policy and practice, and associate professor of medicine at Brown School of Public Health, said in a press release. “The study showed that making mammograms free led to an increase in their use. That is good for public health.”
The ACA required most private insurance plans and Medicare eliminate cost-sharing for preventive services that are recommended by the U.S. Preventive Services Task Force. The goal of eliminating copayments for higher-value care was to increase the use of these services and improve public health.
Women are disproportionately affected by out-of-pocket payments for preventive services, such as mammographs and Pap smears. Of 44 USPSTF recommendations for preventive care, 26 apply specifically to women, and none apply specifically to men.
Even modest costs lower the rates of preventive care received. Trivedi and colleagues previously showed that copayments of $20 led to up to an 11-percentage-point drop in breast cancer screening.
The USPSTF recommends women aged 50 to 74 years at average risk for breast cancer undergo biennial screening.
Trivedi and colleagues conducted a difference-in-differences study to determine whether the elimination of cost-sharing increased biennial screening mammography rates among older women, and whether this impact varied according to race, ethnic group and socioeconomic status.
The analysis included 15,085 women aged 64 to 75 years (mean age, 67.6 years; 81% white) in 24 Medicare Advantage plans that eliminated cost-sharing and fully covered mammography screening and 52,035 women (mean age, 67.8 years; 80% white) in 48 matched control plans that provided full coverage for mammography before and after the ACA mandate.
Adjusted rates of biennial screening mammography increased from 59.9% (95% CI, 54.9-65) in the 2-year period before the ACA mandate to 65.4% (95% CI, 61.8-69) in the 2-year period after among plans that eliminated cost-sharing.
Rates changed from 73.1% (95% CI, 69.2-77) to 72.8% (95% CI, 69.7-76) among control plans.
These results equated to a difference-in-differences of 5.7 percentage points (95% CI, 3-8.4) overall, or 9.8 percentage points (95% CI, 4.5-15.2) among women living in areas with the highest quartile of education attainment compared with 4.3 percentage points (95% CI, 0.2-8.4) among women living in the lowest quartile.
Researchers found the rate of biennial mammography screening increased 6.5 percentage points (95% CI, 3.7-9.4) among white women and 8.4 percentage points (95% CI, 2.5-14.4) among black women but remained virtually unchanged for Hispanic women, at 0.4 percentage points (95% CI, –7.3 to 8.1).
“We have work to do when it comes to women with less education and Hispanic women,” Trivedi said. “They need to be better aware of the cost-sharing provisions of the ACA.”
These results should be considered by lawmakers given the potential repeal of the ACA, according to researchers.
“Our latest findings extend those of previous studies showing that, among older women, receipt of screening mammography is sensitive to out-of-pocket costs and the presence of supplemental coverage,” Trivedi said. – by Alexandra Todak
Disclosures: Trivedi reports personal fees from Merck Foundation outside the submitted work. Please see the full study for all other authors’ relevant financial disclosures.
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