title: Cancer preventive services, socioeconomic status, and the Affordable Care Act.
abstract: Out-of-pocket expenditures are thought to be an important barrier to the receipt of cancer preventive services, especially for those of a lower socioeconomic status (SES). The Affordable Care Act (ACA) eliminated out-of-pocket expenditures for recommended services, including mammography and colonoscopy. The objective of this study was to determine changes in the uptake of mammography and colonoscopy among fee-for-service Medicare beneficiaries before and after ACA implementation.
  
  
  
  Using Medicare claims data, this study identified women who were 70 years old or older and had not undergone mammography in the previous 2 years and men and women who were 70 years old or older, were at increased risk for colorectal cancer, and had not undergone colonoscopy in the past 5 years. The receipt of procedures in the 2-year period before the ACA's implementation (2009-2010) and after its implementation (2011 to September 2012) was also identified. Multivariate generalized estimating equation models were used to determine the independent association and county-level quartile of median income and education with the receipt of testing.
  
  
  
  For mammography, a lower SES quartile was associated with less uptake, but the post-ACA disparities were smaller than those in the pre-ACA period. In addition, mammography rates increased from the pre-ACA period to the post-ACA period in all SES quartiles. For colonoscopy, in both the pre- and post-ACA periods, there was an association between uptake and educational level and, to some extent, income. However, there were no appreciable changes in colonoscopy and SES after implementation of the ACA.
  
  
  
  The removal of out-of-pocket expenditures may overcome a barrier to the receipt of recommended preventive services, but for colonoscopy, other procedural factors may remain as deterrents. Cancer 2017;123:1585-1589. © 2017 American Cancer Society.
authors.affiliation: Division of Gastroenterology, University Hospitals Cleveland Medical Center, Cleveland, Ohio.|Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio.
authors.forename: Gregory S
authors.initials: GS
authors.lastname: Cooper
authors.affiliation: Division of Gastroenterology, University Hospitals Cleveland Medical Center, Cleveland, Ohio.
authors.forename: Tzuyung Doug
authors.initials: TD
authors.lastname: Kou
authors.affiliation: Department of Health Policy, George Washington University, Washington, DC.
authors.forename: Avi
authors.initials: A
authors.lastname: Dor
authors.affiliation: Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio.|Department of Epidemiology and Biostatistics, Case Western Reserve University School of Medicine, Cleveland, Ohio.
authors.forename: Siran M
authors.initials: SM
authors.lastname: Koroukian
authors.affiliation: Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio.
authors.forename: Mark D
authors.initials: MD
authors.lastname: Schluchter
mesh_terms: D000368:Aged; D001943:Breast Neoplasms / Q000000981:diagnostic imaging / Q000517:prevention & control*; D003113:Colonoscopy / Q000706:statistics & numerical data*; D015179:Colorectal Neoplasms / Q000175:diagnosis / Q000517:prevention & control*; D055088:Early Detection of Cancer / Q000706:statistics & numerical data*; D018588:Fee-for-Service Plans; D005260:Female; D005102:Health Expenditures; D006801:Humans; D008297:Male; D008327:Mammography / Q000706:statistics & numerical data*; D006278:Medicare; D009369:Neoplasms / Q000175:diagnosis / Q000517:prevention & control; D058991:Patient Protection and Affordable Care Act; D011314:Preventive Health Services / Q000706:statistics & numerical data*; D012923:Social Class; D014481:United States
keywords: Affordable Care Act; cancer screening; colonoscopy; mammography; socioeconomic factors