Observational Study
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Oncol. Sep 15, 2023; 15(9): 1653-1661
Published online Sep 15, 2023. doi: 10.4251/wjgo.v15.i9.1653
Utilization of access to colorectal cancer screening modalities in low-income populations after medicaid expansion
Gerald Fletcher, Joan Culpepper-Morgan, Alvaro Genao, Eric Alatevi
Gerald Fletcher, Joan Culpepper-Morgan, Alvaro Genao, Eric Alatevi, Department of Gastroenterology, NYC Health + Hospitals/Harlem, New York, NY 10037, United States
Gerald Fletcher, College of Public Health/Health Policy and Management, University of Arizona, Tucson, AZ 85006, United States
Author contributions: Fletcher G designed the study and performed the analysis; Fletcher G, Culpepper-Morgan J, Genao A, and Alatevi E were involved in the initial draft and final version of the manuscript.
Institutional review board statement: This study was deemed by our institution’s IRB as exempt. The data used is from the Behavioral Risk Factor Surveillance System (BRFSS) which is a de-identified and a publicly available dataset.
Informed consent statement: Not applicable given that data is de-identified and publically available. Study is deemed IRB exempt.
Conflict-of-interest statement: Disclosures of financial arrangements by authors: No conflicts of interest exist. Funding sources, funding sources or institutional or corporate affiliations by authors: None; Grant support: None Writing Assistance: None.
Data sharing statement: Technical appendix, statistical code and dataset available from corresponding author at pkfletcher@gmail.com.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Gerald Fletcher, MD, Doctor, Department of Gastroenterology, NYC Health + Hospitals/Harlem, 506 Lenox Ave, New York, NY 10037, United States. pkfletcher@gmail.com
Received: May 29, 2023
Peer-review started: May 29, 2023
First decision: July 23, 2023
Revised: July 31, 2023
Accepted: August 15, 2023
Article in press: August 15, 2023
Published online: September 15, 2023
Research background

Wide disparities exist in access to screening, management, treatment and outcomes of colorectal cancer (CRC) in the United States. With many barriers previously described, various health policies and interventions have been designed to address these disparities. With the passage of the Affordable Care Act about a decade ago, many researchers have shown that Medicaid expansion has led to an increase in insurance coverage but the actual utlization of this newly gained access especially by low-income populations and minority groups remain poorly described in the era of Medicaid expansion.

Research motivation

There are many factors at play in understanding healthcare disparities and outcomes including the interplay between individual and societal factors.

Research objectives

To investigate the effect of Medicaid expansion on low-income populations and minorities on utilization of access to various colon cancer screening modalities. Understanding utilization after Medicaid expansion is key in further decreasing gaps and barriers in CRC screening in the United States.

Research methods

Our study used a quasi-experimental design (a “natural” experiment) given that only some states expanded Medicaid while others did not. Data was from the Behavioral Risk Factor Surveillance System for the period 2011 to 2016. The treatment variable for this study was Medicaid expansion status. A difference-in-differences technique was used to analyze the effect of Medicaid expansion status on the utilization of access to colorectal screening. Other secondary analysis included stratification of the access by ethnicity/race, income, and education status.

Research results

States that expanded Medicaid showed a greater increase in utilization of access to CRC screening. Among minority populations, our analysis revealed that Hispanics showed a greater statistically significant increase in utilization of access but not Non-Hispanic Blacks, or Multiracial. Low-income participants showed a higher change in access and utilization between the expansion periods compared with higher income groups. There was an increase in utilization across all educational levels particularly among those who reported having a high school graduate degree or more.

Research conclusions

We conclude that Medicaid expansion under the ACA was associated with an overall increase in self-reported use of CRC screening tests by adults aged 50-64 years in the United States. This finding was consistent across low-income populations, but not across all races or levels of education. We suggest that despite equally gained access by low-income populations in expansion states, there may be other barriers to CRC screening that exist in Black and other Non-Hispanic multiracial groups including psychosocial and economic determinants of CRC screening choices.

Research perspectives

Future studies should consider investigating economic determinants of CRC screening choices in minority populations.