Lindsay M. Sabik, PhD; Anushree M. Vichare, PhD; Bassam Dahman, PhD; and Cathy J. Bradley, PhD
Co-payments for preventive services can discourage breast and cervical cancer screening among Medicaid enrollees, particularly breast cancer screening, which is more costly and time-consuming.
Objectives: This study investigated the relationship between state Medicaid co-payment policies and cancer screening for Medicaid-enrolled women.
Study Design: Cross-sectional analysis of administrative claims and enrollment data.
Methods: Our data included Medicaid Analytic eXtract (MAX) outpatient claims files across 43 states in 2003, 2008, and 2010, the years for which both MAX data and state cost-sharing data were available. Data on enrollee demographics and screening services from enrollment and claims files were merged with state-year data on co-payment policies and county-level controls from the Area Health Resources File. Participants were nonelderly, nondisabled, nonpregnant women in the recommended age range for each screening service (50-64 years for mammograms; 21-64 years for Pap tests) enrolled in fee-for-service Medicaid. The main independent variable is whether an enrollee faced cost sharing for preventive services. We examined 3 categories of cost sharing: co-payments for all visits, including for preventive services; co-payments for outpatient visits but waived for preventive services; and no co-payments. The main outcome measure was receipt of mammogram or Pap test within a 12-month period.
Results: Medicaid enrollees with co-payments for preventive services were less likely to receive both screening mammograms and Pap tests than enrollees in states not requiring cost sharing for preventive services.
Conclusions: Co-payments for preventive services discourage breast and cervical cancer screening among Medicaid enrollees. The effect is larger for breast cancer screening, which is costlier and requires an additional visit. Considering this evidence, cost sharing for preventive services may lead to adverse health consequences and greater long-term costs.
Am J Manag Care. 2020;26(2):69-74
Co-payments for preventive services can discourage breast and cervical cancer screening among Medicaid enrollees. Such cost sharing may lead to adverse health consequences and greater costs.
- Analysis of outpatient claims files across 43 states from 2003, 2008, and 2010 indicated that Medicaid enrollees facing co-payments for preventive services were less likely to receive both screening mammograms and Pap tests than those without co-payments.
- Ongoing changes to Medicaid policy across multiple states that emphasize cost sharing and consumer-directed healthcare principles should carefully consider the impact of out-of-pocket cost on receipt of preventive care and other high-value services.
Morbidity and mortality from breast and cervical cancer can be reduced through screening.1,2 Breast cancer is the second leading cause of cancer death among US women.3 Although the prevalence of cervical cancer is low in the United States, it could be practically eliminated through screening and treatment for precancerous lesions.4 However, cancer-related disparities persist among women of low socioeconomic status, for whom out-of-pocket costs are often a barrier to seeking screening and treatment for cancer.5-7
Although cost sharing in Medicaid is typically low, most states require co-payments from adult enrollees8,9 and, in some states, cost sharing is on the rise.10 Beginning in 2013, the Affordable Care Act (ACA) incentivized states to eliminate cost sharing for preventive care, offering a 1% increase in the federal match rate for states that cover recommended preventive services without cost sharing.11,12 In contrast, to curb healthcare utilization, CMS encouraged states to increase cost sharing for certain services for nondisabled adults in Medicaid.13 While the policy debate over the role of cost sharing in the Medicaid program continues, evidence regarding the impact of cost sharing on utilization of different types of services is needed to inform policy and programmatic decisions.14
Preventive care such as cancer screening is potentially of high value and has benefits for population health.15 For example, since its implementation, routine screening has led to a substantial decrease in deaths from cervical cancer.16 However, cost sharing may discourage the use of these services, particularly among low-income women who have few resources and do not habitually seek cancer screening, often leading to late-stage diagnosis and poor prognosis.17-19
Several studies have examined the role of cost sharing in healthcare utilization. The seminal RAND Health Insurance Experiment, which randomized families to insurance plans with various levels of cost sharing, found that those with greater out-of-pocket costs had significantly lower healthcare utilization.20 Findings of recent studies suggest negative effects of co-payments on healthcare utilization for Medicaid and other low-income populations across multiple types of care, but few studies have focused on preventive services.21-23 Within the Medicare population, even co-payments as low as $10 are associated with significantly lower rates of mammography in managed care plans.24 Although these studies suggest that co-payments reduce utilization, evidence is needed on the effect of co-payments on receipt of preventive care for Medicaid enrollees, who are vulnerable due to their low income, risk factors (eg, smoking, obesity, comorbid conditions), and lack of access to care. One recent study examined the association of multiple Medicaid policies (not focusing primarily on cost sharing) with receipt of cancer screenings using a single year of data and found that enrollees in states requiring a co-payment for physician services were less likely to receive certain screening services, including mammograms and Pap tests.18 The current study uses multiple years of data and detailed information on cost-sharing policies to evaluate how state-level Medicaid cost-sharing policies influence breast and cervical cancer screening among nonelderly, nondisabled adult enrollees.
Data and Study Sample
We used 3 data sets to examine the association between state Medicaid cost-sharing policies and breast and cervical cancer screening. Information on state Medicaid cost-sharing policies came from Kaiser Family Foundation surveys of states on Medicaid policy benefits.8,9,25-28 Data on Medicaid enrollees and their use of screening services came from the Medicaid Analytic eXtract (MAX) files. The MAX personal summary file provides enrollees’ eligibility pathway, demographics, and type of Medicaid enrollment (managed care or fee-for-service [FFS]). Utilization data for breast and cervical cancer screening came from the MAX other therapy claims file. We used data for years 2003, 2008, and 2010, during which both MAX data and state cost-sharing data were available. We supplemented these data sets with county-level variables from the Area Health Resources File, linked to the MAX data using county-level Federal Information Processing System codes to control for area-level sociodemographic characteristics (as a proxy for individual-level socioeconomic variables not in the claims files) and for local healthcare provider supply.