Secondary Logo

Journal Logo

The ACA and Cancer Screening and Diagnosis

Sabik, Lindsay M. PhD*; Adunlin, Georges PhD

doi: 10.1097/PPO.0000000000000261
Review Articles
Free
SDC

The Patient Protection and Affordable Care Act (ACA) included multiple provisions expected to increase cancer screening and subsequently early diagnosis of cancer. Key provisions included new coverage options for low-income adults and young adults, as well as elimination of cost sharing for recommended preventive services across most health insurance plans. This article reviews relevant quantitative studies published since the ACA’s passage to assess whether the goal of increasing access to preventive services has been met. Because of lags in data availability, most studies examined only a short period post-ACA. Findings on changes in screening in the general population were mixed, although impacts were greatest among those with lower education and income, as well as groups that previously faced the highest cost barriers to screening. Furthermore, multiple studies found evidence of increases in early-stage diagnoses for certain cancers. Thus, certain targeted populations appear to have better access to cancer screening after the ACA.

Supplemental digital content is available in the text.

From the *Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA; and †Cancer Prevention and Control Postdoctoral Fellow, Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, VA.

Conflicts of Interest and Source of Funding: L.M.S. was supported in part by a grant from the National Institutes of Health (R01CA178980, cofunded by the National Cancer Institute and the Office of Behavioral and Social Sciences Research). G.A. was supported by the Virginia Commonwealth University Massey Cancer Center under a Postdoctoral fellowship in cancer prevention and control. The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

Reprints: Lindsay M. Sabik, PhD, Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, 130 De Soto St, Pittsburgh, PA 15261. E-mail: lsabik@pitt.edu.

Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.journalppo.com).

There is broad agreement among key organizations that population-wide screening for certain cancers is an important strategy to improve population health.1 One of the objectives of the Healthy People 2020 initiative is to “reduce the number of new cancer cases, as well as the illness, disability, and death caused by cancer.”2 Yet, historically, levels of screening have been far below goals such as those set by Healthy People 2020, and there have been disparities in screening by socioeconomic status (SES), race, and ethnicity.3 Disparities in receipt of cancer screening are caused by a complex interplay of factors, with access to care playing a key role.3 Lack of insurance coverage has been one important barrier leading to underscreening and disparities in screening.4 The United States has long had a rate of uninsurance that is considerably higher than that of industrialized peer nations.5 The Patient Protection and Affordable Care Act (ACA) responded to this need by aiming to substantially expand access to health insurance coverage in the United States.

The ACA is expected to affect receipt of cancer screening and subsequent diagnosis primarily through 2 mechanisms: expanded health insurance coverage options and coverage requirements for clinical preventive services for most types of public and private health insurance. First, a key feature of the ACA was the expansion of Medicaid to adults with incomes at or below 138% of the federal poverty level. Low-income childless adults were typically ineligible for Medicaid and had relatively low rates of health insurance coverage prior to the ACA. While a 2012 Supreme Court decision made the Medicaid expansion optional for states, a total of 32 states, including the District of Columbia, had expanded Medicaid by 2017.6 Second, the ACA established health insurance marketplaces to allow individuals to shop for health insurance coverage, apply for financial assistance, and purchase coverage without medical underwriting.7 Third, the law required plans and insurers offering dependent coverage to allow young adult dependents to remain on a parent’s plan until the age of 26 years.8 Finally, the ACA required Medicare and nongrandfathered private health insurance policies to provide coverage for preventive care services with a grade of A or B by the US Preventive Services Task Force (USPSTF) without cost sharing.9 Recommended services at the time of the ACA implementation included screening for colon, breast, and cervical cancer. Prior to the ACA, Medicare enrollees without supplemental insurance coverage were responsible for up to 20% of the cost of screening services, and privately insured individuals could be responsible for various forms of cost sharing, including copayments, coinsurance, and meeting plan deductibles; this could amount to substantial out-of-pocket costs for some screening services.10 Of note, annual screening mammography represents a unique example where the ACA’s provisions requiring first dollar coverage for services extend beyond biennial screening that is currently recommended by the USPSTF.

The ACA offered new opportunities for access to care and to cancer screening services in particular, as a result of the law’s provisions implementing new options for insurance coverage and removing potential cost barriers to preventive services. In this article, we review existing evidence of the ACA’s impact on cancer screening and diagnosis. Evidence on the ACA’s impact highlights considerations for how future changes to the ACA and US health policy more generally are likely to impact access to cancer screening, diagnoses of cancer, and disparities in prevention and outcomes.

Back to Top | Article Outline

METHODS

We performed a literature search to identify published articles examining the impact of the ACA on cancer screening and diagnosis. Inclusion criteria applied were (1) English-language articles, (2) studies published in a peer-reviewed journal, (3) studies based on US populations, (4) studies published from March 2010 (when the ACA was signed into law) to January 2017, (5) studies that focus on the impacts of the ACA, (6) empirical studies using quantitative data (excluding, e.g., review articles, editorial or comment articles, case reports, and case series), and (7) studies that examine selected impact measures (screening or diagnosis) and focus on USPSTF recommendations for screening (e.g., mammography, colonoscopy). Details on the search strategy may be found in Appendix A, Supplemental Digital Content 1, http://links.lww.com/PPO/A23.

Back to Top | Article Outline

RESULTS

Figure 1 illustrates the study identification, screening, and selection process. Details on study approaches and quality are presented in Appendix B, Supplemental Digital Content 1, http://links.lww.com/PPO/A23. Reflecting all their differences, the methodological scoring for the studies was highly varied (quality scores ranged from 0.33 to 0.83 on a scale from 0 to 1). We identified 14 studies that estimated the effect of 1 or more provisions of the ACA on cancer screening or diagnosis (Table 1). A few studies considered the impacts of new insurance coverage pathways. One national study specifically examined the effect of the 2014 state-level Medicaid expansions on use of preventive services, including Papanicolaou tests, breast examinations, and mammograms for women using data from the Behavioral Risk Factor Surveillance System (BRFSS) survey.11 The authors did not find evidence of an impact of Medicaid expansions on screening, although given that the relevant questions are only included in the BRFSS in even years, they had only 1 post-implementation year of data on screening outcomes. Two studies considered the impact of the dependent coverage mandate on young adults targeted by the provision compared with control adults not affected and found evidence of increases in early-stage diagnoses for cancer sites detectable by screening or clinical examination.12,13

FIGURE 1

FIGURE 1

TABLE 1

TABLE 1

A number of studies considered screening among both the privately insured and Medicare enrollees in recommended age ranges. In a pre/post analysis using the National Health Interview Survey data that pooled privately insured and Medicare enrolled adults, increases in colorectal cancer screening were observed, driven by changes among low-SES and Medicare-insured individuals, although no changes in breast cancer screening were observed.14 In contrast, a study that considered changes in receipt of preventive services between 2009 and 2012 for both nonelderly and elderly adults using the Medical Expenditure Panel Survey (MEPS) did not find evidence of statistically significant increases in breast, cervical, or colorectal cancer screening.15 Analysis of colorectal cancer screening based on MEPS data similarly found no evidence of increases in overall screening in either population, but did find that colonoscopy increased among Medicare enrollees with no additional insurance and those living in poverty.16 Another study that pooled administrative data on mammography from a large community-based health system found evidence that the ACA increased mammography among women in the recommended age range based on intervention analysis with time-series data.17

Other studies focused exclusively on changes in screening for Medicare enrollees similarly found some evidence of increases, particularly for subgroups expected to benefit most, but mixed results depending on screening modality and subpopulation. Specifically, research using BRFSS survey data found increases in colonoscopy among Medicare-enrolled men, with largest increases among low-SES men, but no increase among women.18 Similarly, data on colorectal cancer screening rates from rural health clinics indicate screening increased after the ACA.19 In contrast, administrative Medicare data for enrollees 70 years or older showed an increase in screening mammography but no increase in screening or surveillance colonoscopy after the ACA.20 Another study found that among women with Medicare there was a modest increase in mammography screening after the elimination of cost sharing.21 Notably, none of the studies considering the impact of cost-sharing elimination for Medicare beneficiaries were able to compare changes in screening to a valid control group, limiting the ability to draw robust conclusions regarding causality. Nonetheless, there is evidence from multiple studies of increases in screening in the Medicare population after the ACA was implemented.14,16,18–21 Furthermore, a recent study considered changes in early-stage diagnoses of cancer among Medicare-aged individuals compared with younger cohorts and found a significant increase in early-stage colorectal cancer diagnoses (and decrease in late-stage diagnoses among men), although there was no evidence of changes in breast cancer stage.22

Finally, 2 studies considered how screening changed for different groups of privately insured individuals after the ACA eliminated cost sharing, and results again were mixed. A natural experiment using data from a large national insurer compared individuals from nongrandfathered plans who were impacted by the policy change to a control group in grandfathered plans and found no changes in mammography or colonoscopy in the treatment group relative to the controls.23 In contrast, individuals who switched into a high-deductible health plan before the elimination of cost sharing for screening reduced their colorectal cancer screening, whereas those who switched after the ACA increased screening, suggesting a substantial relative difference as a result of the ACA.24

Table 2 summarizes studies published after the passage of the ACA that drew implications regarding the likely impact of the ACA’s provisions on screening and diagnosis but did not directly evaluate the effects of the law. Overall, these studies suggest that insurance coverage25,26 and cost-sharing reductions27,28 are generally associated with increased use of screening services, although methodology and study quality vary, and not all results support this conclusion.29 One identified study also suggests that increased coverage options for young adults with cancer may improve outcomes, given insurance coverage was associated with improved stage at diagnosis, treatment, and mortality outcomes.30 While the studies generally suggest that the ACA is likely to lead to improvements in screening and early diagnosis, they also highlight that given variation in Medicaid expansion across states, existing disparities in screening may be expected to widen nationally after ACA implementation.31,32 Furthermore, given remaining gaps in insurance coverage under the ACA’s provisions, projections of the number of women likely to remain uninsured highlight the potential continued need for support of screening services for uninsured women through the Centers for Disease Control and Prevention’s Breast and Cervical Cancer Early Detection Program.33,34

TABLE 2

TABLE 2

Finally, Table 3 summarizes key studies considering the impact of the 2006 Massachusetts health reform on cancer screening. The ACA was modeled in large part on the Massachusetts legislation, so evidence of the impacts of Massachusetts reform can shed light on potential longer-term impacts of the ACA. Results from these studies generally indicate that Massachusetts health reform increased access to various screening services.35–39 Whereas 1 early study did not find an association between Massachusetts reform and increased rates of mammography or changes in stage at breast cancer diagnosis,40 other studies that used a longer time period after expansion suggest a significant impact on screening.36–39 Despite similarities between the Massachusetts health reform and the ACA, the experience in Massachusetts may not generalize to other states, particularly given the very low uninsurance rate in the state before insurance expansion. Even so, the success of the Massachusetts health reform is an indication that over time federal reform may impact cancer-related outcomes beyond what the current literature suggests.

TABLE 3

TABLE 3

Back to Top | Article Outline

DISCUSSION

While the ACA substantially decreased uninsurance and improved access to health care,41 the evidence of the impact of the ACA on cancer screening is more mixed. The lack of strong consensus conclusions from literature up to this point is at least in part the result of the limited number of studies, methodological limitations, and the fact that current data allow assessment of only the short-term impact of the reform. Despite mixed findings, evidence to date suggests that impacts on screening were greatest among those with lower education and income, as well as groups that faced the highest cost barriers to screening prior to the ACA.14,16,18,24 Thus, key populations targeted by the ACA’s provisions appear to have benefited the most in terms of access to cancer screening. The ACA has not removed all barriers to cancer screening. Nonfinancial barriers, such as provider availability and lack of awareness, require alignment of insurance coverage reforms with prevention and public health efforts.

In addition to the need for research that tracks longer-term effects of the ACA on screening, there are a number of areas where more research on the law’s impact on cancer screening and diagnosis is needed. The studies we reviewed do not address changes in racial/ethnic disparities in cancer screening and diagnosis after the ACA. While disparities in health insurance coverage declined during the initial years of the ACA,42 we do not know how this has impacted long-standing racial, ethnic, and geographic disparities in screening.43–45 Furthermore, access to health care and insurance coverage are closely related to the issues of overscreening and overdiagnosis.46 Literature on the early impact of the ACA has not assessed whether the law increased likelihood of overscreening and overdiagnosis for certain cancers. Existing research on screening changes under the ACA generally assumes either implicitly or explicitly that increases in screening will only improve population health. However, policy changes may also incentivize screenings that carry more risks than benefits.

Taken altogether, the reviewed studies suggest that the ACA had an impact on cancer screening and supported earlier diagnosis, although findings differ across populations and screening modalities. Multiple studies found evidence of substantial impacts among populations expected to benefit most, including low-SES groups and groups subject to high cost sharing prior to the ACA. At the time of this writing, the ACA is at the center of political debate over health care reform, and multiple plans for repeal or revision of the law have been proposed. Development of a comprehensive alternative to the ACA should take into account the likely impact of changes on cancer prevention and early detection, as well as health disparities. Evidence indicates that the preventive services mandate and the dependent coverage expansion have increased screening and early diagnosis of some cancers in certain populations; thus, these or similar provisions may be central to continued efforts to reach national screening rate targets and reduce disparities in cancer screening and diagnosis.

Back to Top | Article Outline

REFERENCES

1. World Health Organization. Early detection of cancer. 2017. Available at: http://www.who.int/cancer/detection/en/. Accessed January 30, 2017.
2. Healthy People 2020 topics and objectives—cancer. Available at: https://www.healthypeople.gov/2020/topics-objectives/topic/cancer. Accessed November 19, 2016.
3. Zonderman AB, Ejiogu N, Norbeck J, et al. The influence of health disparities on targeting cancer prevention efforts. Am J Prev Med. 2014;46:S87–S97.
4. DeVoe JE, Fryer GE, Phillips R, et al. Receipt of preventive care among adults: insurance status and usual source of care. Am J Public Health. 2003;93:786–791.
5. Schoen C, Osborn R, Squires D, et al. Access, affordability, and insurance complexity are often worse in the United States compared to ten other countries. Health Aff (Millwood). 2013;32:2205–2215.
6. Status of State Action on the Medicaid Expansion Decision. 2017. Available at: http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/. Accessed August 15, 2016
7. Burke A, Misra A, Sheingold S. Premium affordability, competition, and choice in the health insurance marketplace, 2014. Available at: https://aspe.hhs.gov/system/files/pdf/76896/2014MktPlacePremBrf.pdf. Accessed April 12, 2017.
8. Blumenthal D, Collins SR. Health care coverage under the Affordable Care Act—a progress report. N Engl J Med. 2014;371:275–281.
9. The Affordable Care Act, Section by Section. 2015. Available at: http://www.hhs.gov/healthcare/about-the-law/read-the-law/. Accessed August 24, 2016.
10. Pyenson B, Scammell C, Broulette J. Costs and repeat rates associated with colonoscopy observed in medical claims for commercial and Medicare populations. BMC Health Serv Res. 2014;14:92.
11. Simon K, Soni A, Cawley J. The impact of health insurance on preventive care and health behaviors: evidence from the first two years of the ACA Medicaid expansions. J Policy Anal Manage. 2017;36:390–417.
12. Robbins AS, Han X, Ward EM, et al. Association between the Affordable Care Act dependent coverage expansion and cervical cancer stage and treatment in young women. JAMA. 2015;314:2189–2191.
13. Han X, Zang Xiong K, Kramer MR, et al. The Affordable Care Act and cancer stage at diagnosis among young adults. J Natl Cancer Inst. 2016;108:10.1093.
14. Fedewa SA, Goodman M, Flanders WD, et al. Elimination of cost-sharing and receipt of screening for colorectal and breast cancer. Cancer. 2015;121:3272–3280.
15. Han X, Robin Yabroff K, Guy GP Jr, et al. Has recommended preventive service use increased after elimination of cost-sharing as part of the Affordable Care Act in the United States? Prev Med. 2015;78:85–91.
16. Richman I, Asch SM, Bhattacharya J, et al. Colorectal cancer screening in the era of the Affordable Care Act. J Gen Intern Med. 2016;31:315–320.
17. Nelson HD, Weerasinghe R, Wang L, et al. Mammography screening in a large health system following the U.S. Preventive Services Task Force recommendations and the Affordable Care Act. PLoS One. 2015;10:e0131903.
18. Hamman MK, Kapinos KA. Affordable Care Act provision lowered out-of-pocket cost and increased colonoscopy rates among men in Medicare. Health Aff (Millwood). 2015;34:2069–2076.
19. Wan TT, Ortiz J, Berzon R, et al. Variations in colorectal cancer screening of Medicare beneficiaries served by rural health clinics. Health Serv Res Manag Epidemiol. 2015;2:1–7.
20. Cooper GS, Kou TD, Schluchter MD, et al. Changes in receipt of cancer screening in Medicare beneficiaries following the Affordable Care Act. J Natl Cancer Inst. 2015;108:1–8.
21. Sabatino SA, Thompson TD, Guy GP Jr, et al. Mammography use among Medicare beneficiaries after elimination of cost sharing. Med Care. 2016;54:394–399.
22. Lissenden B, Yao NA. Affordable Care Act changes to Medicare led to increased diagnoses of early-stage colorectal cancer among seniors. Health Aff (Millwood). 2017;36:101–107.
23. Mehta SJ, Polsky D, Zhu J, et al. ACA-mandated elimination of cost sharing for preventive screening has had limited early impact. Am J Manag Care. 2015;21:511–517.
24. Wharam JF, Zhang F, Landon BE, et al. Colorectal cancer screening in a nationwide high-deductible health plan before and after the Affordable Care Act. Med Care. 2016;54:466–473.
25. Wright BJ, Conlin AK, Allen HL, et al. What does Medicaid expansion mean for cancer screening and prevention? Results from a randomized trial on the impacts of acquiring Medicaid coverage. Cancer. 2016;122:791–797.
26. Mahal BA, Aizer AA, Ziehr DR, et al. The association between insurance status and prostate cancer outcomes: implications for the Affordable Care Act. Prostate Cancer Prostatic Dis. 2014;17:273–279.
27. Jena AB, Huang J, Fireman B, et al. Screening mammography for free: impact of eliminating cost sharing on cancer screening rates. Health Serv Res. 2016;52:191–206.
28. Khatami S, Xuan L, Roman R, et al. Modestly increased use of colonoscopy when copayments are waived. Clin Gastroenterol Hepatol. 2012;10:761–766.
29. Atherly A, Mortensen K. Medicaid primary care physician fees and the use of preventive services among Medicaid enrollees. Health Serv Res. 2014;49:1306–1328.
30. Aizer AA, Falit B, Mendu ML, et al. Cancer-specific outcomes among young adults without health insurance. J Clin Oncol. 2014;32:2025–2030.
31. Choi SK, Adams SA, Eberth JM, et al. Medicaid coverage expansion and implications for cancer disparities. Am J Public Health. 2015;105(suppl 5):S706–S712.
32. Sabik LM, Tarazi WW, Bradley CJ. State Medicaid expansion decisions and disparities in women’s cancer screening. Am J Prev Med. 2015;48:98–103.
33. Ku L, Bysshe T, Steinmetz E, et al. Health reform, Medicaid expansions, and women’s cancer screening. Womens Health Issues. 2016;26:256–261.
34. Levy AR, Bruen BK, Ku L. Health care reform and women’s insurance coverage for breast and cervical cancer screening. Prev Chronic Dis. 2012;9:E159.
35. Clark CR, Soukup J, Govindarajulu U, et al. Lack of access due to costs remains a problem for some in Massachusetts despite the state’s health reforms. Health Aff (Millwood). 2011;30:247–255.
36. Clark CR, Soukup J, Riden H, et al. Preventive care for low-income women in Massachusetts post-health reform. J Womens Health (Larchmt). 2014;23:493–498.
37. Okoro CA, Dhingra SS, Coates RJ, et al. Effects of Massachusetts health reform on the use of clinical preventive services. J Gen Intern Med. 2014;29:1287–1295.
38. Sabik LM, Bradley CJ. The impact of near-universal insurance coverage on breast and cervical cancer screening: evidence from Massachusetts. Health Econ. 2016;25:391–407.
39. Van der Wees PJ, Zaslavsky AM, Ayanian JZ. Improvements in health status after Massachusetts health care reform. Milbank Q. 2013;91:663–689.
40. Keating NL, Kouri EM, He Y, et al. Effect of Massachusetts health insurance reform on mammography use and breast cancer stage at diagnosis. Cancer. 2013;119:250–258.
41. Sommers BD, Gunja MZ, Finegold K, et al. Changes in self-reported insurance coverage, access to care, and health under the Affordable Care Act. JAMA. 2015;314:366–374.
42. Chen J, Vargas-Bustamante A, Mortensen K, et al. Racial and ethnic disparities in health care access and utilization under the Affordable Care Act. Med Care. 2016;54:140–146.
43. Liss DT, Baker DW. Understanding current racial/ethnic disparities in colorectal cancer screening in the United States: the contribution of socioeconomic status and access to care. Am J Prev Med. 2014;46:228–236.
44. Tatalovich Z, Zhu L, Rolin A, et al. Geographic disparities in late stage breast cancer incidence: results from eight states in the United States. Int J Health Geogr. 2015;14:31.
45. Khan-Gates JA, Ersek JL, Eberth JM, et al. Geographic access to mammography and its relationship to breast cancer screening and stage at diagnosis: a systematic review. Womens Health Issues. 2015;25:482–493.
46. Morris LG, Sikora AG, Tosteson TD, et al. The increasing incidence of thyroid cancer: the influence of access to care. Thyroid. 2013;23:885–891.
Keywords:

Cancer care; diagnosis; health care reform; Patient Protection and Affordable Care Act; screening

Supplemental Digital Content

Back to Top | Article Outline
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.