The Affordable Care Act and cancer screening in Medicare

Universal screening for breast and colorectal cancers are currently recommended as methods to reduce the mortality associated with these diseases. Mammography is capable of detecting cancer before it has the opportunity to invade into lymph nodes or other organs, and colonoscopy is able to not only detect early stage cancers, but by removing precancerous polyps, prevent cancer from developing. Although both procedures have been covered by insurance, patients often faced significant deductibles and/or copayments. Thus, there is evidence that members of lower socioeconomic groups are less likely to be screened with mammography and colonoscopy, with out-of-pocket expenses associated with these tests being an important barrier. The Affordable Care Act (ACA), which among other features, waived all out-of-pocket expenditures for recommended preventive services, was enacted in the United States in 2011 for Medicare beneficiaries.

So did the ACA have an impact on screening mammography and colonoscopy in Medicare? Previous studies of initiation of Medicare reimbursement for routine mammography and colonoscopy found increased use after implementation. With this in mind, we hypothesized that the ACA’s elimination of copayments and deductibles would promote uptake of these preventive screenings.

We found that whereas monthly mammography use after the ACA was enacted did increase by approximately 2% compared with the pre-ACA period of 2009–10 (Figure 1), colonoscopy uptake was stagnant (Figure 2). We found that individuals in the “younger” age groups of Medicare (less than 75), who would derive the greatest longevity benefit from early detection, did have a larger uptake in mammography and colonoscopy than others. Also, patients who utilized the Medicare Wellness Visits, which are designed in part to provide a schedule of preventive services, were also more likely to undergo testing.

Graphs originally from “Changes in Receipt of Cancer Screening in Medicare Beneficiaries Following the Affordable Care Act“. Created by and used with permission from the authors.

Although the study was limited to older patients and only looked at the first two years of ACA coverage (2011-2012), we found mixed results for the ACA’s impact in this population. Compared to colonoscopy, because mammography does not require other preparation and is noninvasive, it may be easier to facilitate in the general population. In contrast, colonoscopy requires a bowel preparation and intravenous sedation and has a small risk of complications and it is not known from our study whether these remained as deterrents to its uptake. Also, because of a loophole in the ACA legislation, colonoscopy procedures that result in removal of polyps are considered diagnostic, even if the indication for the procedure was preventive. Although there are ongoing attempts to fix this loophole through legislation, at this time, diagnostic procedures are still subject to copayments. It is uncertain whether this was another barrier to colonoscopy receipt.

Our findings suggest that elimination of out-of-pocket expenditures is an important step to increase the uptake of preventive services, especially mammography. Other recommended cancer preventive services, including Pap testing and fecal occult blood testing are also covered in full by the ACA and the impact of the legislation on the uptake of these procedures is not known. However, keep in mind that follow-up procedures to evaluate positive tests are considered diagnostic, not preventative, and are subject to copayments. We would suggest that further studies should examine the long-term impact of the ACA in other patient groups, including privately insured and Medicaid recipients. In addition, other benefits of the ACA in improving access to care such as expansion of Medicaid eligibility in a subset of states should be evaluated.

Image credit: Photo by GDJ. CC0 Public Domain via Pixabay.