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Cervical and colorectal cancer screening prevalence before and after T
Aﬀordable Care Act Medicaid expansion
Nathalie Hugueta, Heather Angiera, Rebecca Rdesinskia, Megan Hoopesc, Miguel Marinoa,b, Heather Holdernessa, , Jennifer E. DeVoea
a Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, United States
b Division of Biostatistics, School of Public Health, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, United States
Keywords: Aﬀordable Care Act
Community health centers (CHCs), which serve socioeconomically disadvantaged patients, experienced an in-crease in insured visits after the 2014 Aﬀordable Care Act (ACA) coverage options began. Yet, little is known about how cancer screening rates changed post-ACA. Therefore, this study assessed changes in the prevalence of cervical and colorectal cancer screening from pre- to post-ACA in expansion and non-expansion states among patients seen in CHCs.
Electronic health record data on 624,601 non-pregnant patients aged 21–64 eligible for cervical or colorectal cancer screening between 1/1/2012 and 12/31/2015 from 203 CHCs were analyzed. We assessed changes in prevalence and screening likelihood among patients, by insurance type and race/ethnicity and compared Medicaid expansion and non-expansion states using diﬀerence-in-diﬀerence methodology.
Despite increased prevalences of cervical and colorectal cancer screening in both expansion and non-ex-pansion states across all race/ethnicity groups, rates remained suboptimal for this KPT 185 of socio-economically disadvantaged patients.
Community health centers (CHCs) provide services across the United States (US) to nearly 28 million patients every year (National Association of Community Health Centers, 2018). CHCs predominately serve low-income, racial and ethnic minorities, and Medicaid bene-ficiaries or uninsured patients (National Association of Community Health Centers, 2018). CHCs reduce barriers to cost (through sliding scale fee structures), accept patients without insurance, and tailor ser-vices to specific populations (e.g., homeless, non-English speakers) (National Association of Community Health Centers, 2018).
Additionally, CHCs oﬀer high quality care, meet or exceed national standards for delivery of many healthcare services (e.g., diabetes care) (National Association of Community Health Centers, 2018), and reduce racial and ethnic health disparities (Politzer et al., 2001; Shi et al., 2004). Despite having access to this excellent care, some patients who seek care in CHCs face barriers to receiving recommended healthcare services (Saloner et al., 2018). For example, patients seen in CHCs have low rates of receiving some preventive care, specialty care, and diag-nostic services; rates diﬀer among patients with and without health insurance (Bailey et al., 2015; Gusmano et al., 2002). In 2010, the Aﬀordable Care Act (ACA) mandated health insurance
Abbreviations: CHC, community health centers; ACA, Aﬀordable Care Act; ADVANCE, Accelerating Data Value Across a National Community health center network; aOR, adjusted odds ratio; CDRN, clinical data research network; CI, confidence interval; EHR, electronic health record; FPL, federal poverty level; FIT, fecal immunochemical test; FOBT, fecal occult blood test; HCN, Health Choice Network; GEE, generalized estimating equation; Pap, Papanicolaou
E-mail address: [email protected] (H. Holderness).
cover preventive services (including cancer screenings) at no out of pocket cost to patients. In addition to ensuring access to preventive services, in 2014, the ACA provided federal financial support to states opting to expand Medicaid eligibility to citizens and legal residents earning ≤138% of the federal poverty level (FPL) and introduced health insurance marketplaces for purchase of individual health in-surance plans. As of January 1, 2019, 36 states (and the District of Columbia) implemented the ACA Medicaid expansion, while 14 states had not (The Henry J Kaiser Family Foundation, 2018). There are many factors that influence the receipt of preventive cancer screenings in-cluding patient characteristics, provider recommendations, health in-surance coverage, and costs (Akers et al., 2007; Crawford et al., 2016; Womeodu and Bailey, 1996). As lack of health insurance is associated with delayed cancer screening and being diagnosed with cancer at later stages compared to those with insurance, it is hypothesized that ACA changes in health insurance availability may have an impact on cancer screening rates among the general population and, perhaps, even more so among patients seen in CHCs (American Cancer Society, 2015; Carney et al., 2012; DeVoe et al., 2003; Palmer and Schneider, 2005; Robinson and Shavers, 2008).