Do Insurance Mandates Reduce Racial Disparities in Colorectal Cancer Screening?

Background: Before the Patient Protection and Affordable Care Act (PPACA), only 35 states had mandated insurance coverage for colorectal cancer screening. Previous studies indicate mandates led to small changes in aggregate CRC screening rates, but effects may be larger among underserved populations. If so, mandates could reduce screening disparities. Racial and ethnic disparities in CRC screening, disease incidence, and mortality are well documented and differences in insurance coverage are often cited as a contributing factor. This study examines whether state mandates reduced racial and ethnic disparities.

Methods: Using a sample of insured individuals age 51 to 64 (n = 286,930) from Behavioral Risk Factor Surveillance System (BRFSS) data, we estimate a logistic Difference in Difference regression of up-to-date screening on mandate enactment, race/ethnicity categorical variables, and interactions using a non-mandate state control group.

Results: We find substantial reductions in screening disparities. Disparities in up-to-date screening between Native Hawaiians/Pacific Islanders and whites were eliminated after mandates (pre-mandate OR = 0.64, post OR = 1.26, χ² p=0.00). Differences between Asians and whites also fell (pre OR = 0.75, post OR = 0.82, χ² p=0.00) Although we found no change in up-to-date disparities for blacks, the black-white endoscopic screening disparity decreased significantly (pre OR = 0.87, post OR = 0.98, χ² p=0.04)

Conclusions: We conclude mandates did reduce racial/ethnic disparities in CRC screening, which implies differences in insurance coverage do contribute to disparities.  Our findings also imply PPACA mandates may further reduce disparities, depending on the racial and ethnic distribution of grandfathered plans.