Medicaid Expansions: Probing Medicaid’s Filling of the Cancer Genetic Testing and Screening Space
1. Introduction: Medicaid Expansion and Cancer
2.1. Recruitment and Conduct
2.2. Policy Analysis
3.1. Breast Cancer Screening
3.2. Hereditary Breast and Ovarian Cancer Genetic Testing
3.3. Colorectal Cancer Screening
3.4. Lynch Syndrome Genetic Testing
5. Conclusion: An Uneven Expansion and Filling
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
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|Condition||Affordable Care Act (ACA) P.L. 111–148  Statement (Abridged)||Related U.S. Preventive Service Task Force (USPSTF) Recommendations (Condensed)|
|SEC. 2713 (a). A group plan or health insurance issuer must not impose cost-sharing requirements for evidence-based items or services that have an A or B rating from the USPSTF; or with respect to women, are provided for in HRSA comprehensive guidelines; or that fit with USPSTF recommendations regarding breast cancer screening, mammography, and prevention||The U.S. Preventive Services Task Force recommends biennial screening mammography for women aged 50 to 74 years. Women at higher risk may benefit from beginning screening in their 40s .|
Screen women who have family members with breast, ovarian, tubal, or peritoneal cancer or who have an ancestry associated with BRCA1/2 gene mutations with an appropriate brief familial risk assessment tool. Women who are positive should receive genetic counseling and, if indicated, genetic testing .
This recommendation applies to women who are asymptomatic for BRCA-related cancer .
|SEC. 2713 (a). A group plan or health insurance issuer must not impose cost-sharing requirements for evidence-based items or services that have an A or B rating from the USPSTF||Screen for colorectal cancer in all adults age 50 to 75 years (A recommendation) and age 45 to 49 years (B recommendation). The risks and benefits of different screening methods vary .|
These recommendations apply only to asymptomatic adults 45 years or older who are at average risk of colorectal cancer, excluding individuals who are at a high lifetime risk, such as for Lynch syndrome and familial adenomatous polyposis .
|SEC. 4106. ELIGIBLE ADULTS IN MEDICAID. Section 1905 (a) of the Social Security Act is amended to read: other diagnostic, screening, preventive services, including any clinical preventive services that are assigned a grade of A or B by the USPSTF||The decision to undergo periodic PSA-based screening for prostate cancer should be an individual one. Men should discuss the potential benefits and harms, and their values and preferences, with their clinician .|
This recommendation does not include the use of the PSA test for surveillance after diagnosis or treatment of prostate cancer and does not consider PSA-based testing in men with known BRCA gene mutations who may be at increased risk for prostate cancer .
Based on the available evidence, the USPSTF is not able to make a separate, specific recommendation on PSA-based screening for prostate cancer in African American men … [or] men with a family history of prostate cancer .
|Condition||ACA HealthCare.Gov Website  |
Preventive Services Description
|ACA HealthCare.Gov Website  Interventions Covered|
|The Affordable Care Act covers mammograms for women over age 50 to 74; and requires health insurance plans to cover these services for women at higher risk of breast cancer:||For women only:|
|Under the Affordable Care Act, most insurance plans must cover screening for colorectal cancer for persons age 45 to 75. The physician helps decide which test is appropriate and how often to get screened. Some tests are done every 1 to 3 years; others every 5 to 10 years.||The ACA website does not list specific colorectal diagnostic interventions. USPSTF recommendations:|
|The ACA Preventive Services website does not specifically list prostate cancer. Medicaid limited benefit programs may cover PSA screening and digital rectal exams.||The ACA website does not list specific prostate cancer diagnostic interventions. USPSTF recommendation: PSA screening should be individualized.|
|Policy Strategy||Advantages||Disadvantages||Impact on |
|Institutional policy changes (increase culturally sensitive services, provider fees)||Enhance willingness to offer/engage in cancer diagnostic services||Increase institutional costs; specialized training required||Increase access to physicians and volume of completed tests and screens||Komenaka et al., 2016 ; |
Kidambi et al., 2016 ; Sabik et al., 2020 
|Implement statewide criteria for Medicaid coverage of cancer genetic testing||Likely first opportunity for patient to move from cancer screening to genetic testing||Need adequate number of genetic counselors||Increase genetic testing rates, leading to more precise personal management and awareness raising in family members||NC Medicaid 2021 ; Durst 2015 |
|Engage more states in Medicaid expansion||Decreased rate of uninsured;|
earlier cancer detection
|Drains state money from other fiscal targets; |
Reduced quality of care, e.g., in appointment availability and wait time
|Reduced number of low-income and racial-ethnic minority uninsured||Cross-Call 2021 ;|
Keith 2021 ;
Artiga et al., 2019 
|State Medicaid block grants||Increased flexibility according to state needs; state can benefit from shared savings||Administrative barriers to new enrollees; coverage of costly healthcare services may not be authorized||Disenrollment of low-income and racial-ethnic minorities; loss of more expensive services||Miller et al., 2021 |
|State shift of Medicaid enrollees to managed care||Spend state dollars more efficiently; increase in preventive care||Inability to obtain cancer genetic testing in those not shifted||More patients screened for breast cancer; less BRCA1/2 and Lynch syndrome testing||FORCE 2021 ; |
Tye et al., 2004 ;
Phillips et al., 2000 
|Support advocacy efforts||Can address coverage gaps and promote new guidelines and legislation; efforts target groups in need||Requires leadership and critical number of grassroots members; need to connect with professional and legislative champions||BRCA1/2 testing coverage for a larger variety of individuals; Lynch syndrome testing only incrementally affected||Modell et al., 2021, 2016 [20,91]|
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Modell, S.M.; Schlager, L.; Allen, C.G.; Marcus, G. Medicaid Expansions: Probing Medicaid’s Filling of the Cancer Genetic Testing and Screening Space. Healthcare 2022, 10, 1066. https://doi.org/10.3390/healthcare10061066
Modell SM, Schlager L, Allen CG, Marcus G. Medicaid Expansions: Probing Medicaid’s Filling of the Cancer Genetic Testing and Screening Space. Healthcare. 2022; 10(6):1066. https://doi.org/10.3390/healthcare10061066Chicago/Turabian Style
Modell, Stephen M., Lisa Schlager, Caitlin G. Allen, and Gail Marcus. 2022. "Medicaid Expansions: Probing Medicaid’s Filling of the Cancer Genetic Testing and Screening Space" Healthcare 10, no. 6: 1066. https://doi.org/10.3390/healthcare10061066