Preventive care can reduce overall healthcare costs and improve patient well-being. Although the evidence is mixed on whether use of cancer preventive screenings for cervical cancer (Papanicolaou, or Pap, test), breast cancer (mammography), colorectal cancer (CRC), blood stool tests (FOBT), colonoscopies, or sigmoidoscopies reduces all-cause mortality, screenings for CRC and breast cancer have been shown to reduce disease-specific mortality [1
]. Regardless, these screening tests are recommended by the United States Preventive Services Task Force (USPSTF) for eligible populations in the United States.
Patient behavior of utilizing preventive healthcare services could be influenced by the presence or absence of patient cost-sharing, i.e., out-of-pocket payments (OOP) in the form of copays or deductibles [5
]. The literature, to a great extent, suggests that the amount of OOP negatively affects the use of recommended screenings for breast and cervical cancers [8
]. To increase the uptake of preventive healthcare services, the Affordable Care Act (ACA), signed into law in the US in March 2010, greatly emphasized disease prevention. According to the ACA’s Preventive Care Provision, beginning September 23, 2010, all non-grandfathered-in private health insurance plans were required to provide coverage for the USPSTF recommended preventive care services without patient cost-sharing [10
]. Beginning January 2011, Medicare was also required to cover the USPSTF recommended preventive care services without patient cost-sharing [10
]. Additionally, starting in January 2014, the ACA prohibited non-grandfathered-in plans to have annual or lifetime dollar limits for “essential health benefits,” which included preventive care services.
Literature from the pre-ACA period suggests a negative [11
] or lack of [16
] association of OOP and utilization of cancer screenings. For instance, Medicare beneficiaries reported lower utilization of mammography when enrolled in health plans with copayments compared to those in plans without copayments and/or those with additional supplemental coverage which protected patients from copayments [11
]. Similarly, individuals aged 18–64 years reported lower utilization of Pap tests and mammography when enrolled in plans with patient cost-sharing compared to others [14
]. However, Medicare beneficiaries [11
] or health maintenance organization enrollees [16
] in the pre-ACA period reported no difference in the utilization of Pap tests when enrolled in health plans with/without copayments. Likewise, a study by Han and colleagues in the post-ACA period found no overall increase in utilization of Pap tests, mammography, or screenings for CRC between the years 2009 and 2011–2012 [18
]. In individuals aged 50–64 years, Richman et al. reported no effect on the utilization of screenings for CRC in the post-ACA period (i.e., 2012 vs. 2009) [19
]. Jenssen et al. also did not find any effects of the elimination of cost-sharing on the utilization of FOBT, prostate-specific antigen tests, and mammography in Medicare beneficiaries in 2008–2010 versus 2012 [20
]. Another recent study did not show any differences in the utilization of cancer screenings before and after the implementation of the ACA [21
]. However, some studies have also demonstrated a positive effect of zero cost-sharing on the utilization of cancer screenings. For instance, in a sub-group analysis by Han and colleagues, women without chronic conditions reported a small increase in the use of mammography in the post-ACA period [18
]. Richman et al. also reported a 12% increase in colonoscopy use among Medicare beneficiaries aged 65–75 years in 2012 (vs. 2009) [19
]. More recently, a cancer registry-based study reported an 8% increase in diagnoses of CRC cases in the post-ACA period [22
]. Overall, the above-presented studies are limited by relatively early and inconsistent findings.
Disparities in receipt of cancer screenings by race/ethnicity have also been extensively reported [23
]. According to the currently available literature, Black Americans are equally or more likely to report utilization of screenings for breast and cervical cancers compared to their White counterparts [23
], which is also true among those who are uninsured [25
]. The evidence about the utilization of screening for CRC is mixed among Black and White Americans [23
]. While in a few studies [23
] Hispanics, Asian-Americans, and Pacific Islanders reported lower utilization of screenings for CRC, breast, and cervical cancers compared to other groups, in more recent studies Hispanic women had a higher likelihood of reporting utilization of screenings for breast cancer [24
] and cervical cancer [25
] compared to non-Hispanic (nH) White women. Additionally, the removal of cost-sharing was positively correlated with the receipt of mammography among a national sample of rural women [32
]. Limited evidence also found differences in the uptake of CRC screenings [33
A recent systematic review concluded, the available evidence regarding cost-sharing and utilization of cancer screening in the ACA era is mixed, with a limited number of studies evaluating the short-term effects [34
]. However, none of the studies included in the review reported the impact of ACA on cancer screenings by race/ethnicity characteristics [34
], despite the well-known disparities in healthcare utilization (including cancer screenings) by race/ethnicity in the US [23
]. Moreover, most studies in the post-ACA period defined the receipt of cancer screening as those received “within past year,” which is inconsistent with the frequency of screening tests as recommended by the USPSTF, necessitating the need for further studies.
This study examined the association between the ACA’s elimination of cost-sharing and the utilization of USPSTF-recommended preventive screenings for cervical cancer, breast cancer, and CRC, stratified by the type of insurance, race/ethnicity, and sex (for CRC screenings). As opposed to the currently available literature, this study adds to the research by providing the updated prevalence of the guideline-concordant utilization of cancer screenings in the overall eligible population, males, females, as well as within specific racial/ethnic groups, using a nationally representative sample in the US.
In this study, we evaluated whether the ACA’s elimination of a cost-sharing provision for preventive care services influenced the USPSTF-concordant utilization of selected cancer screenings. To provide a comprehensive report, we stratified the analysis by three insurance groups, and also by race/ethnicity for all screenings and by sex for CRC screenings. Our results suggest the following: (a) utilization of Pap tests in the post-ACA period has generally declined in privately-insured women, however, it has increased in Hispanic Medicare-only women; (b) utilization of mammography in the post-ACA period has declined in privately-insured women where the reduction is greatest in nH Asians, though there are no differences in the uptake of mammography in the Medicare-only group; and (c) utilization of CRC screenings has increased in males and females of all race/ethnicities with private insurance in the post-ACA periods, while its utilization has increased in Hispanic Medicare-only beneficiaries, regardless of sex.
The declining trend in the utilization of recommended Pap tests in privately-insured women in this study is in line with recent data from the Centers for Disease Control and Prevention [29
]. However, it is in contrast to previous studies from the pre- and post-ACA periods, which demonstrated negative [14
] or a lack of [11
] association between cost-sharing and the uptake of Pap tests. A reason for the decline in Pap tests, specifically after 2012, could be due to the updated guidelines. According to the new updates, women could have a Pap test every five years if they had it in combination with the HPV test [36
]. However, the unavailability of information about HPV testing in MEPS data limited our ability to confirm this reasoning. On the Medicare-only side, the elimination of cost-sharing appeared to benefit the Hispanic population, as we observed an increase in the use of Pap tests in the early post-ACA period (2011). However, in the other post-ACA periods, the rise in utilization was not statistically significant.
The stable-declining trend in the uptake of mammography is also in accordance with recent reports [29
]. Fedewa and colleague’s analysis of the National Health Interview Survey reported a 3.2% decline in mammography in 2013 (vs. 4% in 2014 this study) compared to pre-ACA periods in privately-insured women [42
]. Even the 16% reduction in mammography screenings among privately-insured nH Asians in this study is similar to a previous report [23
]. One of the well-known hypotheses for the reduction in rates of mammography is that women no longer visit physicians for hormone therapy prescriptions—which is usually the visit in which they are referred to mammography—because of a greater risk of breast cancer with use of hormone therapy [44
]. Consistent with previous studies [18
], we did not find significant differences in rates of mammography among Medicare-only beneficiaries across pre-ACA and post-ACA periods.
The findings regarding the rise in CRC screenings in this study are consistent with recent studies by Fedewa et al [42
]. and Richman et al. [19
]. However, they are in contrast to the study by Cooper et al [48
], which reported on only colonoscopies among ≥70 year-old Medicare beneficiaries. Other reports from the Department of Health and Human Services also suggest an overall increase in the use of preventive care services by Medicare beneficiaries [49
]. However, our observation of an increase in CRC screenings across all years of post-ACA periods was limited to Hispanic Medicare-only beneficiaries. The rise in utilization of screenings for CRC in the post-ACA period observed in this study among privately-insured individuals could, in part, also be attributed to the newly gained coverage among those who were previously uninsured. Given the simultaneous implementation of the ACA to mandate/expand insurance and the elimination of cost-sharing associated with preventive services, it is difficult to isolate the effects of each of these changes.
The extent of awareness about the ACA’s zero cost-sharing requirements for preventive care services is poor, which may have resulted in the decreased utilization of preventive care services observed in this study. According to a recent survey, only less than half of the Americans were aware of this policy [51
]. Thus, there is a need to create awareness about the benefits of such a policy. Further, the grandfathered-in plans were not required to implement the zero cost-sharing policy. However, close to 50% participants in the Kaiser survey still reported having grandfathered-in plans [51
]. Creating more awareness about the zero cost-sharing provision to both policyholders and clinicians would help in improving the screening rates. Finally, personal factors such as beliefs and perceptions about screening and its associated risks could also play a role in explaining the declining trends observed in this study.
While there are strengths to our study, such as the use of nationally representative data and the USPSTF-concordant definitions for receipt of cancer screenings, there are also some limitations. Responses to receipt of cancer screening were based on self-reported data, which are prone to recollection or recall bias [52
], as well as underreporting of utilization [53
]. However, we expect that any extent of recall and underreporting would have been similar across the study years, potentially not affecting the results in our study. Further, due to lack of information from the MEPS, we were unable to differentiate between grandfathered-in and non-grandfathered-in private plans. Lastly, the co-occurring policy changes (such as the change in guidelines for mammography and the addition of HPV testing for cervical cancer), and other concurrent events that influenced the survival of the ACA, could have affected our findings and subsequent interpretation.