Extending rates to non-expansion states would have led to 355,184 additional screenings
A new ACS study examining Medicaid expansion and cancer screening finds that the five states and District of Columbia that first adopted Medicaid expansion saw larger increases in colorectal cancer (CRC) screening than those states that did not expand Medicaid. The study, appearing early online in the American Journal of Preventive Medicine, estimates that if non-expansion states had experienced the same increase in recent colorectal cancer screening as the very early expansion states, an additional 355,184 people would have been screened.
The Affordable Care Act (ACA) was enacted in 2010 and provided federal support for states to expand Medicaid insurance coverage to low-income adults, a group with limited access to preventive services. Five states and the District of Columbia were very early adopters and expanded Medicaid eligibility in 2010−2011. An additional twenty-one states expanded their Medicaid programs during 2014; five states expanded in 2015-2016, and 19 states did not expand.
To find out whether the timing of Medicaid expansion improved screening prevalence, the current study, led by Stacey A. Fedewa, PhD (pictured here), senior principal scientist in our Surveillance and Health Services Research department, examined temporal changes in screening patterns among low-income adults in all states, using data from the 2012, 2014, and 2016 Behavioral Risk Factor Surveillance System (BRFSS), a state-based telephone survey overseen by the Centers for Disease Control and Prevention (CDC).
Between 2012 and 2016, the proportion of low-income adults ages 50 to 64 who were up-to-date with CRC screening grew by 8.8 percentage points in very early adopters (from 42.3% to 51.1%), by 2.9 percentage points in early adopters (from 49.6% to 52.5%), and by 3.8 percentage points in non-expansion states (from 44.2% to 48.0%). The magnitude of this change was greatest in very early versus non-expansion states. Recent CRC screening (defined as having a colonoscopy, stool testing or sigmoidoscopy in the past two years) increased by 8 percentage points (from 30.1% to 38.1%) in very early states and 2.8 percentage points (from 29.1% to 31.8%) in non-expansion states. The improvement in screening rates in very early expansion states translated to an additional 236,573 low-income adults receiving recent CRC screening in 2016. If the same absolute increase was experienced in non-expansion states, 355,184 more low-income adults would have had recent CRC screening than what was observed.
“Health insurance is a strong predictor of cancer screening, and the uninsured and those with lower socioeconomic status are more likely to be diagnosed at late stage and die from screen-detectable cancers, including colorectal cancer,” said Stacey.
The authors note that the growth in CRC screening prevalence in the very early expansion states was not immediate and that changes in CRC screening among those expanding Medicaid later were comparable to non-expansion states. That may reflect the lag time between people gaining insurance and completing the multi-step screening process that typically relies on a physician visit, followed by a recommendation, and then a follow-up visit with a specialist if a colonoscopy is performed.
“It is likely that the full impact of Medicaid expansions on cancer screening may not yet be fully visible and the previously reported modest improvements in early stage at diagnosis for screen detectable cancers could progress further,” write the authors.
They also found breast cancer screening increased only modestly among low-income women residing in expansion states. That could be due to more widespread and historical support for mammography in low income populations through initiatives like CDC’s National Breast and Cervical Cancer Early Detection Program, as well as programs offered by non-profits, and mobile mammography clinics. Also, mammography has far fewer financial and logistic barriers than colonoscopy as it is cheaper and requires less preparation.