Annual routine check-ups, flu shots, and mammograms are among the basic preventive services for which the Patient Protection and Affordable Care Act of 2010 established a mandate for insurance plans: full coverage, with no out-of-pocket costs. In making it a little easier for some parts of the US population to access basic services, did the ACA result in increased uptake of these services? A new article just out in this month’s issue of Medical Care has some answers.
The researchers, led by Young-Rock Hong at the University of Florida, used Medical Expenditure Panel Survey (MEPS) data from 2007-2014 to study two cohorts of people aged 18-64: those who were continuously enrolled in private insurance, and those who were continuously uninsured. Then, they used a difference-in-differences (DiD) design to examine rates of preventive care between those cohorts from 2007-2010 (pre-ACA) and 2011-2014 (post-ACA).
Looking only at the significant results, the authors found that:
- Flu vaccinations increased slightly among the privately insured and decreased slightly among the uninsured, resulting in a DiD effect of 5.9 percentage points. This was the only outcome that significantly changed both pre-post and between the two cohorts.
- Blood pressure evaluations increased slightlyamong private insurees relative to the uninsured (3.3 points)
- Routine checkups also increased slightlyamong private insurees relative to the uninsured (2.7 points)
- Cholesterol checks increased slightly among private insurees pre-post (3 points)
- The rates for Pap smears and mammograms decreased slightly among private insurees pre-post (-3.1 and -4.7 points, respectively)
- Turing to costs, the privately insured group had significantly higher total healthcare costs after the ACA (pre-post, mean total costs increased from $5,031 to $5,138), but lower out-of-pocket costs (decreased from $721 pre-ACA to $638 post-ACA).
These moderate positive effects are somewhat encouraging, but the negative effects on cancer screening are unfortunate. Type of insurance is another concern–earlier work showed some differences in response to cost based on plan type. However, it is not just cost that acts as a barrier to accessing preventive care. Other countries that have adopted national cancer screening programs, such as Australia, have provided workable models for increasing cancer screening. Reducing cost barriers is just the start.
In another analysis, using 2006-07 MEPS data, my coauthors and I found that intermittent insurance was a significant predictor of lack of preventive care. During that time period, about 1 in 5 individuals aged 18-64 had a gap in coverage. Since the ACA allowed coverage lapses of up to 3 months without a tax penalty, gaps in coverage have continued to be common: in 2013, 27% of people under age 65 (73.0 million individuals) were uninsured for 1 or more months.
People with lapses in coverage were excluded from the study by Hong and colleagues. More research is needed in this area, especially since the prevalence of intermittent insurance is likely to increase without enforcement of the ACA’s individual mandate.
In addition, the future of these coverage benefits remains murky, since some conservatives see the mandates as governmental overreach. Various Republican proposals have removed the mandates or would allow insurers to offer plans without them. But even without legislation, the Trump administration has the ability to make changes through the regulatory process.
Some argue that waiving co-payments for these relatively inexpensive, routine preventive services is the opposite of what insurance should do — that insurance should be reserved for catastrophic and unexpected costs. But from a population health perspective, removing barriers to access is a strategy that clearly can work to increase uptake of screening.
Lisa M. Lines