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
Abstract
BACKGROUND

Colorectal cancer (CRC) remains a relevant public health problem. Current research suggests that racial, economic and geographic disparities impact access. Despite the expansion of Medicaid eligibility as a key component of the Affordable Care Act (ACA), there is a dearth of information on the utilization of newly gained access to CRC screening by low-income individuals. This study investigates the impact of the ACA’s Medicaid expansion on utilization of the various CRC screening modalities by low-income participants. Our working hypothesis is that Medicaid expansion will increase access and utilization of CRC screening by low-income participants.

AIM

To investigate the impact of the Affordable Care Act and in particular the effect of Medicaid expansion on access and utilization of CRC screening modalities by Medicaid state expansion status across the United States.

METHODS

This was a quasi-experimental study design using data from the Behavioral Risk Factor Surveillance System, a large health system survey for participants across the United States and with over 2.8 million responses. The period of the study was from 2011 to 2016 which was dichotomized as pre-ACA Medicaid expansion (2011-2013) and post-ACA Medicaid expansion (2014-2016). The change in utilization of access to CRC screening strategies between the expansion periods were analyzed as the dependent variables. Secondary analyses included stratification of the access by ethnicity/race, income, and education status.

RESULTS

A greater increase in utilization of access to CRC screening was observed in Medicaid expansion states than in non-expansion states [+2.9%; 95% confidence interval (95%CI): 2.12, 3.69]. Low-income participants showed a +4.02% (95%CI: 2.96, 5.07) change between the expansion periods compared with higher income groups +3.19% (1.70, 4.67). Non-Hispanic Whites and Hispanics [+3.01% (95%CI: 2.16, 3.85) vs +5.51% (95%CI: 2.81, 8.20)] showed a statistically significant increase in utilization of access but not in Non-Hispanic Blacks, or Multiracial. There was an increase in utilization across all educational levels. This was significant among those who reported having a high school graduate degree or more +4.26 % (95%CI: 3.16, 5.35) compared to some high school or less +1.59% (95%CI: -1.37, 4.55).

CONCLUSION

Medicaid expansion under the Affordable Care Act led to 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 all low-income populations, but not all races or levels of education.

Keywords: Medicaid expansion, Colorectal cancer screening, Low-income, Disparities, Minorities, Affordable care act

Core Tip: While many researchers have shown and studied how the Affordable Care Act through its Medicaid’s expansion increased healthcare access to different categories of potential beneficiaries, little is known about actual utilization of this “newly gained” access. Our paper focuses specifically on examining this specific question.