Increased use of recommended clinical preventive services among adults, such as colorectal and breast cancer screening and influenza vaccination, may save up to 100,000 lives per year and vastly improve life expectancy among the US population. Despite these benefits, recommended preventive services have been underused. In this post, I focus on colorectal cancer screening among adults between 50 and 75 years of age.
In 2010, the U.S. Centers for Disease Control and Prevention (CDC) found that only 64.5% of targeted adults were up-to-date on recommended colorectal cancer screening. Those least likely to be up-to-date on colorectal cancer screening were individuals with less than a high school education (45%) and with annual household incomes below $35,000 (56% for $15,000-$34,999 and 48% for <$15,000).
Barriers to obtaining screening are many and complex. I, for one, have a hard time explaining why I have not yet called to schedule my annual mammography screening. My doctor provided an order over 5 months ago, the mammography center is conveniently located, I bear no financial costs for the test, and I could be in and out in less than 30 minutes. For me, the barriers are difficult to pinpoint. But for some people, cost is a very real barrier to receiving preventive services.
Kaiser Family Foundation found in 2013 that 20% of women and 16% of men put off receiving preventive services because of cost. Not surprisingly, among people who were uninsured, the fraction that postponed receiving prevention was significantly higher than among the insured (for women, 52% among uninsured versus 13% among insured; for men, 42% among uninsured versus 9% among insured). To address cost as a barrier to receiving preventive services, the Affordable Care Act (ACA) required that most private health insurance plans fully cover recommended preventive services, including colorectal cancer screenings for adults. As a result of this ACA provision, approximately 76 million Americans have received coverage for one or more preventive services.
To examine whether the ACA preventive services provision led to increased screening among individuals covered by private insurance, a new Medical Care article by Wharam and colleagues compared colorectal screening rates in members of a high deductible health plan before and after the ACA provision. By using a control group of health plan members who faced a lower annual deductible ($500 versus $1000), the researchers were able to identify the extent to which the ACA coverage provision resulted in an increase in colorectal cancer screening among those in the high deductible plan. They observed a significant increase in colorectal cancer screening rates (9% higher) and in screening colonoscopies (16% higher) following ACA implementation.
The article provides important evidence that cost was a very real barrier to colorectal cancer screening prior to the ACA. Once preventive services were available at no cost to plan participants, cancer screenings increased. However, to meaningfully increase use of preventive screening services, other (non-cost) barriers also need to be addressed, such as patient access and education and providers’ tendency to focus on treatment versus prevention.
Speaking of barriers, I am my own worst enemy. Because I have no excuse not to call and schedule a mammogram, I just made an appointment. I hope you too will take advantage of expanded health care coverage for preventive services and schedule those routine appointments. Just think of the life-years you stand to gain.
Amanda Honeycutt
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