Medicaid Expansion and Colorectal Cancer Screening
A new study examining Medicaid expansion and cancer screening found that the five states and District of Columbia that first adopted Medicaid expansion saw larger increases in colorectal cancer screening than states that did not expand Medicaid. The study—published by Fedewa et al in the American Journal of Preventive Medicine—estimated that if nonexpansion 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.
Medicaid Expansion
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 21 states expanded their Medicaid programs during 2014, 5 states expanded in 2015–2016, and 19 states did not expand.
Study Methods and Findings
To find out whether the timing of Medicaid expansion improved screening prevalence, the current study, led by Stacey A. Fedewa, PhD, Senior Principal Scientist in the Surveillance and Health Services Research Department at the American Cancer Society, examined temporal changes in screening patterns among low-income adults in all states. The investigators used data from the 2012, 2014, and 2016 Behavioral Risk Factor Surveillance System, 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 aged 50 to 64 who were up-to-date with colorectal cancer screening grew by 8.8 percentage points in very early adoption states (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 nonexpansion states (from 44.2% to 48.0%). The magnitude of this change was greatest in very early vs nonexpansion states.
Recent colorectal cancer screening (defined as having a colonoscopy, stool testing, or sigmoidoscopy in the past 2 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 nonexpansion states. The improvement in screening rates in very early expansion states translated to an additional 236,573 low-income adults receiving recent colorectal cancer screening in 2016. If the same absolute increase was experienced in nonexpansion states, 355,184 more low-income adults would have had recent colorectal cancer 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 Dr. Fedewa.
The authors noted that the growth in colorectal cancer screening prevalence in the very early expansion states was not immediate, and that changes in colorectal cancer screening among those expanding Medicaid later were comparable to nonexpansion states. That may reflect the lag time between people gaining insurance and completing the multistep 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,” wrote the authors.
Breast Cancer Screening
The team 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 nonprofits and mobile mammography clinics, in addition to the fewer financial and logistic barriers for mammography vs colonoscopy.
Disclosure: For full disclosures of the study authors, visit ajpmonline.com.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
