title: Changes in Receipt of Cancer Screening in Medicare Beneficiaries Following the Affordable Care Act.
abstract: BACKGROUND
  The Affordable Care Act (ACA) removed copayments for screening mammography and colonoscopy in Medicare beneficiaries, but its clinical impact is unknown.
  
  
  METHODS
  Using a 5% random sample of Medicare claims from 2009 through 2012 in individuals age 70 years or older who were due for screening, we examined claims for screening mammography and screening or surveillance colonoscopy for two years prior to ACA (2009-2010) and two years post-ACA (2011-2012). Receipt of the procedures at the patient level was compared across years using generalized estimating equations. Statistical tests were two-sided.
  
  
  RESULTS
  Compared with 2009, we found an increase in mammography uptake during the ACA coverage period, with multivariable odds ratios (MOR) of 1.22 (95% confidence interval [CI] = 1.20 to 1.25, P < .001) for 2011 and 1.17 (95% CI = 1.15 to 1.20, P < .001) for 2012 and less change in 2010 (OR = 1.03, 95% CI = 1.01 to 1.05, P = .01). In contrast to mammography, uptake of screening or surveillance colonoscopy decreased in 2012 (MOR = 0.95, 95% CI = 0.92 to 0.98, P = .002) compared with 2009, with no change in 2010 (MOR = 1.01, 95% CI = 0.99 to 1.04, P = .47) or 2011 (MOR = 1.01, 95% CI = 0.99 to 1.04, P = .34). Other factors associated with procedure receipt included younger age and prior preventive health visits. In an analysis restricted to patients age 70 to 74 years, colonoscopy use increased slightly in 2011 but was unchanged in 2012, and the findings by year for mammography were consistent with the main analysis.
  
  
  CONCLUSIONS
  Following ACA implementation with concomitant reduction in out-of-pocket expenditures, there was a statistically significant increment in mammography uptake but not colonoscopy. This suggests that affordability is a necessary but not sufficient facilitator of preventive services.
authors.affiliation: Division of Gastroenterology, University Hospitals Case Medical Center, Cleveland, OH (GSC, TDK); Comprehensive Cancer Center (GSC, MDS, SMK) and the Department of Epidemiology and Biostatistics (SMK), Case Western Reserve University School of Medicine, Cleveland, OH; Department of Health Policy, George Washington University, Washington, DC (AD). gregory.cooper@uhhospitals.org.
authors.forename: Gregory S
authors.initials: GS
authors.lastname: Cooper
authors.affiliation: Division of Gastroenterology, University Hospitals Case Medical Center, Cleveland, OH (GSC, TDK); Comprehensive Cancer Center (GSC, MDS, SMK) and the Department of Epidemiology and Biostatistics (SMK), Case Western Reserve University School of Medicine, Cleveland, OH; Department of Health Policy, George Washington University, Washington, DC (AD).
authors.forename: Tzuyung D
authors.initials: TD
authors.lastname: Kou
authors.affiliation: Division of Gastroenterology, University Hospitals Case Medical Center, Cleveland, OH (GSC, TDK); Comprehensive Cancer Center (GSC, MDS, SMK) and the Department of Epidemiology and Biostatistics (SMK), Case Western Reserve University School of Medicine, Cleveland, OH; Department of Health Policy, George Washington University, Washington, DC (AD).
authors.forename: Mark D
authors.initials: MD
authors.lastname: Schluchter
authors.affiliation: Division of Gastroenterology, University Hospitals Case Medical Center, Cleveland, OH (GSC, TDK); Comprehensive Cancer Center (GSC, MDS, SMK) and the Department of Epidemiology and Biostatistics (SMK), Case Western Reserve University School of Medicine, Cleveland, OH; Department of Health Policy, George Washington University, Washington, DC (AD).
authors.forename: Avi
authors.initials: A
authors.lastname: Dor
authors.affiliation: Division of Gastroenterology, University Hospitals Case Medical Center, Cleveland, OH (GSC, TDK); Comprehensive Cancer Center (GSC, MDS, SMK) and the Department of Epidemiology and Biostatistics (SMK), Case Western Reserve University School of Medicine, Cleveland, OH; Department of Health Policy, George Washington University, Washington, DC (AD).
authors.forename: Siran M
authors.initials: SM
authors.lastname: Koroukian
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000517:prevention & control*; D003110:Colonic Neoplasms / Q000517:prevention & control*; D003113:Colonoscopy / Q000191:economics* / Q000706:statistics & numerical data; D055088:Early Detection of Cancer / Q000191:economics* / Q000379:methods / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008297:Male; D008327:Mammography / Q000191:economics* / Q000706:statistics & numerical data; D006278:Medicare / Q000191:economics / Q000331:legislation & jurisprudence / Q000639:trends; D016017:Odds Ratio; D058991:Patient Protection and Affordable Care Act; D011159:Population Surveillance / Q000379:methods; D011322:Primary Prevention / Q000191:economics / Q000331:legislation & jurisprudence / Q000379:methods; D012494:Sampling Studies; D014481:United States / Q000453:epidemiology