Screening Rate Disparities for Some Cancers May Have Decreased After ACA, Study Finds

According to a new study, socioeconomic disparities in mammography rates among Medicare beneficiaries decreased after the implementation of the Affordable Care Act (ACA), but the same pattern was not observed for colonoscopies. The researchers hypothesize that the free preventive services required under the ACA may have removed cost as a barrier, but other obstacles to cancer screening persist.

The study, published in Cancer, looked at 2 samples of Medicare beneficiaries aged 70 or older and determined whether they had received the recommended cancer screening based on the date of their most recent preventive mammography or colonoscopy. They also collected information on patients’ cancer risk factors and county-level income and education data. The mammography analysis included a sample of over 862,000 women, while the colonoscopy sample included over 326,000 men and women.

The researchers explained that the ACA’s provision eliminating out-of-pocket costs to patients for preventive services was intended to expand access to screening and reduce disparities, but few studies had compared screening rate changes after the ACA. Thus, their study conducted analyses to compare screening rates and their relation to income and education factors in the 2-year period before the ACA was implemented (2009 to 2010) and the 2-year period after implementation (2011 to 2012).

For the mammography group, the researchers found an association between lower socioeconomic status and decreased mammography rates, both before and after the ACA went into effect, but the disparities decreased significantly after the law’s implementation. The odds ratio for the women in the lowest-income quartile receiving a mammogram compared with those in the highest quartile of income increased from 0.87 to 0.94 after the ACA, while the corresponding odds ratios for education quartiles increased from 0.76 to 0.86. From the pre-ACA period to the post-ACA period, the researchers found that mammography rates increased within each quartile of income and education.

In the colonoscopy analysis, however, the researchers observed a slight decrease in colonoscopy rates after the ACA was implemented, and found that there were no significant changes in the associations between socioeconomic indicators and screening rates over the study period. “The interaction tests indicate that the effects of income, education, and quartile did not differ significantly between the 2 time periods,” the authors wrote.

The researchers acknowledged that they could not establish a causal relationship between the ACA and screening rates. They wrote that the mammography findings indicated that the financial cost of preventive services may have been a potential obstacle to cancer screening, but it is far from the only factor.

“The findings support the removal of out-of-pocket expenditures as a barrier to the receipt of recommended preventive services but emphasize that for colonoscopy, other factors such as a fear of sedation, perceived discomfort, and a need for bowel preparation should be considered,” they concluded.

The researchers also suggested that further studies be undertaken to assess the effects of the ACA on screening rates among other populations, such as people who gained insurance coverage under the law.