title: The association between state mandates of colorectal cancer screening coverage and colorectal cancer screening utilization among US adults aged 50 to 64 years with health insurance.
abstract: BACKGROUND
  Several states in the US have passed laws mandating coverage of colorectal cancer (CRC) screening tests by health insurance plans. The impact of these state mandates on the use of colorectal cancer screening has not been evaluated among an age-eligible target population with access to care (i.e., health care insurance coverage).
  
  
  METHODS
  We collected information on state mandates implemented by December 31, 2008 and used data on insured adults aged 50 and 64 years from the Behavioral Risk Factor Surveillance System between 2002 and 2008 to classify individual-level exposure to state mandates for at least 1 year. Multivariate logistic regression models (with state- and year- fixed effects, and patient demographic and socioeconomic characteristics) were used to estimate the effect of state mandates on recent endoscopy screening (either flexible sigmoidoscopy or colonoscopy during the past year).
  
  
  RESULTS
  From 1999-2008, twenty-two states in the US, including the District of Columbia passed comprehensive laws requiring health insurance coverage of CRC screening including endoscopy tests. Residence in states with CRC screening coverage mandates in place for at least 1 year was associated with a 1.4 percentage point increase in the probability of utilization of recent endoscopy (i.e., 17.5% screening rates in those with mandates versus 16.1% in those without, Adjusted OR = 1.10, 95% CI: 1.02-1.20, p = 0.02).
  
  
  CONCLUSIONS
  The findings suggest a positive, albeit small, impact of state mandates on the use of recent CRC screening endoscopy among the target eligible population with health insurance. However, more research is needed to evaluate potential effects of mandates across health insurance types while including controls for other system-level factors (e.g. endoscopy and primary care capacity). National health insurance reform should strive towards a system that expands access to recommended CRC screening tests.
authors.affiliation: Surveillance and Health Policy Research, American Cancer Society, Atlanta, USA. vcokkini@cancer.org
authors.forename: Vilma
authors.initials: V
authors.lastname: Cokkinides
authors.forename: Priti
authors.initials: P
authors.lastname: Bandi
authors.forename: Mona
authors.initials: M
authors.lastname: Shah
authors.forename: Katherine
authors.initials: K
authors.lastname: Virgo
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Ward
mesh_terms: D040343:Behavioral Risk Factor Surveillance System; D015179:Colorectal Neoplasms / Q000175:diagnosis*; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D019458:Insurance Coverage / Q000331:legislation & jurisprudence*; D016015:Logistic Models; D008297:Male; D037141:Mandatory Programs / Q000331:legislation & jurisprudence*; D008403:Mass Screening / Q000706:statistics & numerical data*; D008875:Middle Aged; D015999:Multivariate Analysis; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D012959:Socioeconomic Factors; D013219:State Government; D011795:Surveys and Questionnaires; D014481:United States