title: Impact of the elimination of cost sharing for mammographic breast cancer screening among rural US women: A natural experiment.
abstract: BACKGROUND
  Rural US women experience disparities in breast cancer screening and outcomes. In 2006, a national rural health insurance provider, the National Rural Electric Cooperative Association (NRECA), eliminated out-of-pocket costs for screening mammography.
  
  
  METHODS
  This study evaluated the elimination of cost sharing as a natural experiment: it compared trends in screening before and after the policy change. NRECA insurance claims data were used to identify all women aged 40 to 64 years who were eligible for breast cancer screening, and mammography utilization from 1998 through 2011 was evaluated. Repeated measures regression models were used to evaluate changes in utilization over time and the association between screening and sociodemographic factors.
  
  
  RESULTS
  The analysis was based on 45,738 women enrolled in the NRECA membership database for an average of 6.1 years and included 279,940 person-years of enrollment. Between 1998 and 2011, the annual screening rate increased from 35% to a peak of 50% among women aged 40 to 49 years and from 49% to 58% among women aged 50 to 64 years. The biennial screening rate increased from 56% to 66% for women aged 40 to 49 years and from 68% to 73% for women aged 50 to 64 years. Screening rates increased significantly (P < .0001) after the elimination of cost sharing and then declined slightly after changes to government screening guidelines in 2009. Younger women experienced greater increases in both annual screening (6.2%) and biennial screening (5.6%) after the elimination of cost sharing in comparison with older women (3.0% and 2.6%, respectively). In a multivariate analysis, rural residence, lower population income, and lower population education were associated with modestly lower screening.
  
  
  CONCLUSIONS
  In a national sample of predominantly rural working-age women, the elimination of cost sharing correlated with increased breast cancer screening. Cancer 2017;123:2506-15. © 2017 American Cancer Society.
authors.affiliation: Massachusetts General Hospital Cancer Center, Boston, Massachusetts.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Peppercorn
authors.affiliation: Massachusetts General Hospital Cancer Center, Boston, Massachusetts.
authors.forename: Nora
authors.initials: N
authors.lastname: Horick
authors.affiliation: Duke University Medical Center, Durham, North Carolina.
authors.forename: Kevin
authors.initials: K
authors.lastname: Houck
authors.affiliation: Massachusetts General Hospital Cancer Center, Boston, Massachusetts.
authors.forename: Julia
authors.initials: J
authors.lastname: Rabin
authors.affiliation: University of Connecticut Health Center, Farmington, Connecticut.
authors.forename: Victor
authors.initials: V
authors.lastname: Villagra
authors.affiliation: Fred Hutchinson Cancer Research Center, Seattle, Washington.
authors.forename: Gary H
authors.initials: GH
authors.lastname: Lyman
authors.affiliation: University of North Carolina School of Global Public Health, Chapel Hill, North Carolina.
authors.forename: Stephanie B
authors.initials: SB
authors.lastname: Wheeler
mesh_terms: D000328:Adult; D001943:Breast Neoplasms / Q000000981:diagnostic imaging*; D002277:Carcinoma / Q000000981:diagnostic imaging*; D017047:Cost Sharing; D055088:Early Detection of Cancer / Q000191:economics / Q000706:statistics & numerical data*; D004522:Educational Status; D005260:Female; D005102:Health Expenditures; D054625:Healthcare Disparities; D006801:Humans; D007182:Income; D008327:Mammography / Q000191:economics / Q000706:statistics & numerical data*; D008875:Middle Aged; D015999:Multivariate Analysis; D012424:Rural Population; D014481:United States
keywords: access to care; breast cancer screening; disparities; health policy; rural health