Published online Sep 15, 2023. doi: 10.4251/wjgo.v15.i9.1653
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
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.
There are many factors at play in understanding healthcare disparities and outcomes including the interplay between individual and societal factors.
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.
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.
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.
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.
Future studies should consider investigating economic determinants of CRC screening choices in minority populations.