More women participated in mammography screening when they no longer had to pay out of pocket for part of the cost, as stipulated by the Affordable Care Act (ACA), found a study published January 17 in the New England Journal of Medicine. The study is the latest to show the ACA as having a positive effect on public health.
Researchers found that the rate of biennial breast screening went up nearly six percentage points in plans that eliminated cost-sharing provisions as required by the ACA. Meanwhile, participation rates didn't change in a control group of plans that maintained full coverage of breast screening.
Despite the improvement, ethnicity and socioeconomic status made a difference in terms of the magnitude of the effect, wrote a team led by Dr. Amal Trivedi of Brown University. And the ACA's uncertain future under the Trump administration could mean that the improvement is short-lived (NEJM, January 17, 2018, 378:3, pp. 262-269).
Paying out of pocket
Numerous previous studies have shown that requiring individuals to pay out of pocket -- in the form of deductibles, co-payments, and the like -- reduces the use of healthcare services, according to the authors. In the case of preventive services, this reduces participation in screening options that have been shown to be effective -- particularly with respect to women, they wrote.
The Affordable Care Act addressed this issue with a provision that required Medicare and most private insurance plans to eliminate cost sharing for preventive services that have been recommended by the U.S. Preventive Services Task Force (USPSTF). Of the 44 preventive services covered by the stipulation, 26 apply specifically to women and none apply only to men.
Trivedi and colleagues wanted to examine the effect of the ACA's full-coverage provision by looking at whether the removal of cost sharing increased the rate of screening mammography compliance among older women. They also wanted to examine whether there were differences in its effect based on race, ethnic group, or socioeconomic status.
The researchers found 24 insurance plans that had required cost sharing for breast screening for at least two years before the ACA provisions went into effect. The level of cost sharing varied by plan: Among the 24 plans, two required co-payments of 20%, while the remaining 22 required payments of $20 to $30.
Of these plans, 17 eliminated cost sharing in 2009, four in 2010, and three in 2011. For comparison, each of the plans was matched with two randomly chosen health plans that operated in the same or a bordering state, giving the group a total of 48 control plans.
The researchers only included women who were 65 years and older and who were eligible for mammography screening every two years, giving them a total of 15,085 women in the intervention plans and 61,164 women in the control plans. Women in the intervention plans were younger, less likely to be a member of a racial or ethnic minority group, and more likely to be living in areas of higher poverty and lower rates of high school completion.
Trivedi and colleagues found that mammography participation in the intervention plans went up after cost sharing was eliminated, while it remained about the same in the control plans.
| Mammography participation after elimination of cost sharing | ||
| Before cost sharing eliminated | After cost sharing eliminated | |
| Plans that eliminated cost sharing | 59.9% | 65.0% |
| Plans that never had cost sharing | 73.1% | 72.8% |
Diving further into the data, they found there was a greater increase in mammography participation in higher-income areas than lower-income areas when cost sharing was eliminated, at 9.8 percentage points versus 4.3 percentage points. On an ethnicity basis, black women saw the biggest increase, at 8.4 percentage points, while participation among white women grew 6.5 percentage points. On the other hand, there was almost no change in participation among Hispanic women, with an increase of 0.4 percentage points.
The authors believe their results could be explained by previous studies suggesting that women of lower educational status have less awareness of the features of health insurance and of the ACA. Hispanic women have been found to have a lower awareness of the ACA than the general population.
"These findings, along with the results of our study, support the importance of outreach to Hispanic women and socioeconomically vulnerable populations about reduction in cost sharing for preventive care and other similar value-based changes in insurance policies," Trivedi and colleagues wrote.
Simply removing co-payments may not be enough to raise breast screening rates to targeted levels, the authors noted. The intervention group still lagged the control group in terms of mammography participation at the end of the study period, and even the control group had fewer than three-quarters of women participating in screening at rates recommended by the USPSTF.
And in any event, the positive effect of eliminating cost sharing may be moot if efforts by the Trump administration to dismantle the ACA continue.
"If the cost-sharing provisions of the ACA are rescinded, our results raise concern that fewer older women will receive recommended breast-cancer screening," the authors wrote.
