br In expansion states when stratified
In expansion states, when stratified by insurance status and race/ ethnicity, the prevalence of colorectal cancer screening pre-ACA was lowest among uninsured or privately insured non-Hispanic white pa-tients (< 7%). Most groups had an increase post-ACA in colorectal cancer screening prevalence. Despite the increases seen, colorectal cancer screening remained low in all groups and especially so among uninsured non-Hispanic white and black patients. Uninsured Hispanic patients had more than double the odds of getting screened post-compared to pre-ACA (aOR = 2.37, 95% CI = 1.78–3.16). In non-ex-pansion states, colorectal cancer screening prevalences were highest among Hispanic patients pre- and post-ACA, with significant improve- r> ment also seen for non-Hispanic black (aOR = 2.03, 95% CI = 1.38–2.99) and non-Hispanic white (aOR = 1.74, 95% CI = 1.24–2.45) patients post-ACA. DID analyses showed that most changes in colorectal cancer screening prevalence over the ACA study LOXL 2IN1 were similar for expansion and non-expansion groups. The only diﬀerence we found was that Hispanic uninsured patients had greater relative increases in colorectal cancer screening prevalence in expan-sion compared to non-expansion states (DID =1.65, 95% CI = 1.11–2.44).
Table 3 Colorectal cancer screening prevalence, pre- and post-ACA by Medicaid expansion status overall and stratified by insurance group and race/ethnicity.
DID (post/pre, expansion/
Pre-ACA Post-ACA Odds of screening, post Pre-ACA Post-ACA Odds of screening, post
Note: ACA = Aﬀordable Care Act; NH = Non-Hispanic; DID = diﬀerence-in-diﬀerence.
Eligible population for colorectal screening: age 50–64 throughout period, without history of total colectomy, due for colorectal cancer screening (no documentation of FOBT/FIT received in past 1 year). Odds ratios and DID ratios were obtained from logistic generalized estimating equation models with a robust sandwich variance estimator specifying an independent working correlation structure of health systems nested within states and adjusted for age, race/ethnicity (for the overall sample), federal poverty level, payer type, urban/rural status, and number of ambulatory visits.
Overall, cervical and colorectal cancer screenings among eligible patients seen in study CHCs improved after ACA Medicaid expansion in both expansion and non-expansion states. Contrary to our hypothesis, we did not find an association between expansion status and increased cancer screening disparities in CHC settings; these results may not apply to non-CHC settings or CHCs not included in the study sample. The improvements in cancer screenings in CHCs suggest that both increased insurance options (Medicaid expansion and subsidized exchange cov-erage) and preventive service coverage requirements (ensuring no out-of-pocket cost to patients for these screenings) helped patients obtain recommended services. Results from this study are in line with single state health insurance expansion analyses (Hendryx and Luo, 2018; Marino et al., 2016; Van Der Wees et al., 2013) demonstrating the positive association between health insurance coverage and cancer screening.
Surprisingly, uninsured patients post-ACA Medicaid expansion saw an increase in cervical and colorectal cancer screenings. These findings are likely due to the additional funding that came from both a rise in overall insured visits and federal grant dollars after ACA Medicaid ex-pansion. Specifically, CHCs experienced increased operating capacity (Han et al., 2017) which allowed them to provide more care, especially preventive care (Han et al., 2017), likely benefiting patients who visited CHCs but remained uninsured.
Results presented in this study also showed that the prevalence of cervical and colorectal cancer screenings were similar across race and ethnicity; in fact, receipt of screenings was often highest among Hispanic patients, especially post-ACA. This result agrees with a few previous studies, which found that Hispanics had higher rates of cer-vical cancer screening than non-Hispanic whites (Cowburn et al., 2013; Owusu et al., 2005) and could result from the important role CHCs play in reducing racial/ethnic health disparities (Politzer et al., 2001; Riedy et al., 2007; Shi et al., 2004). Some of the strategies CHCs use to reduce disparities include: providing additional non-healthcare services to
mitigate access barriers (e.g., transportation assistance, child care) and oﬀering health education, counseling, and case management. Another explanation for these findings may be that CHCs access the Centers of Disease Prevention and Control grant funding to provide cancer screenings to their uninsured and/or Hispanic patients. Specifically, the National Breast and Cervical Cancer Early Detection Program (https:// www.cdc.gov/cancer/nbccedp/) provides access to breast and cervical cancer screening to low-income women and is strongly utilized by Hispanic women (Centers for Disease Control and Prevention, n.d.). This program funds screening tests through grants to those providing the services and may help explain the ability of those without insurance to receive these screenings. Similarly, programs and initiatives such as Colorectal Cancer Control Program (available in 6 states in our study) and the National Colorectal Cancer Roundtable Initiative (National Colorectal Cancer Roundtable, 2015) (which has the goal of reaching ≥80% CRC screening by 2018) may have facilitated access to color-ectal cancer screening in several states.