Within his first days in office, President Donald Trump signed an executive order granting federal agencies greater power to waive provisions of the Affordable Care Act deemed too costly for the insurer, such as the ACA’s removal of co-payments for mammograms and colonoscopies.
Removing these co-payments was an attempt to address the barriers that many, namely low-income Americans, faced in receiving these life-saving screenings. A new study supports this, finding that, since implementation of the ACA and its elimination of out-of-pocket expenses, there has been an increase in mammograms, but not colonoscopies.
“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,” says Gregory Cooper of University Hospitals Cleveland Medical Center.
While the American Cancer Society recommends regular mammograms for women beginning at 45 years old and regular colonoscopies for everyone 50 and older, about one-third of women are not receiving regular mammograms and about one-third of both women and men are not receiving regular colonoscopies. Though those numbers are still low, at least for mammograms, it marks a significant uptick from pre-ACA figures: As many as 61 percent of under-insured women reported not receiving a mammogram within the last two years pre-ACA.
To arrive at those post-ACA numbers, Cooper and his colleagues turned to Medicare claims data, following 862,267 women for mammogram use and 326,503 men and women for colonoscopy use. Nearly 87 percent of the mammogram participants were white, while 8.2 percent were African American; of the colonoscopy group, 89.9 percent were white, while 6.3 percent were African American.
A low-income woman was 13 percent less likely to receive a mammogram before the ACA.
Within these sample sizes, the researchers identified women who had not received mammograms in the last two years, and men and women who had not received colonoscopies in the last five years. Among both populations, there was a significant correlation between socioeconomic status and cancer screening rates: Those who identified as low-income were less likely to receive a screening.
Comparing pre- and post-ACA Medicare data, the researchers found that, while socioeconomic gaps continued to exist in who received mammograms, the margin was significantly reduced post-ACA. Results showed, for example, that a low-income woman was 13 percent less likely to receive a mammogram before the ACA; that number decreased to 6 percent after the ACA. In addition, mammogram screenings exhibited a general uptick in use across socioeconomic class post-ACA.
Researchers attribute this increase in mammograms to “the removal of out-of-pocket expenditures.” Prior to the ACA, Medicare beneficiaries were required to pay a 20 percent co-insurance payment for a mammography; this payment was removed after the ACA. Removal of this financial barrier allowed low-income women to pursue services they otherwise may not have been able to afford.
A 25 percent co-insurance for colonoscopies was also removed post-ACA, but colonoscopies did not exhibit a significant uptick across socioeconomic class or in general after the ACA.
“I would speculate that there are other barriers that need to be overcome [for a colonoscopy]: fear of the procedure and possible complications, anticipated pain, unwillingness to do a bowel prep, inability to have a driver after sedation, etc.,” Cooper says. The American Cancer Association supports Cooper’s claim, citing patients’ fear that “the test is difficult or painful” in addition to feeling embarrassment over discussing the exam.
The researchers concluded that the ACA reduced socioeconomic disparities for at least mammography, which supports the removal of out-of-pocket expenditures for cancer prevention services.
Despite this evidence, the Trump administration seems to be moving quickly to eliminate these ACA provisions, prompting many to scramble for new solutions.