Can removing out-of-pocket costs for screening save lives? Screening for cancer and other diseases can identify the disease in its earlier stages of development and has been found to be highly effective in preventing the onset of illness. For example, screening by colonoscopy for colorectal cancer, the second leading cause of cancer death in the US, leads to a 90% reduction in cancer cases and a 67% reduction in deaths. Nevertheless, overall colorectal screening rates remained low (65% of US adults aged 50-75 years) before 2010, likely due to high out-of-pocket costs to cover this $1000+ procedure. The Patient Protection and Affordable Care Act (ACA), passed in 2010, eliminated out-of-pocket costs for colorectal cancer screening and other preventive services, including contraception and diabetes screening.
Researchers at the Yale School of Public Health and Kaiser Permanente of Northern California (KPNC) thus set out to investigate the precise effect of the ACA on colorectal cancer cases and deaths. Spearheaded by Donna Spiegelman of Yale, the study team included Catherine Lee, Lawrence H. Kushi, Mary E. Reed, Elizabeth H. Eldridge, Jeffrey K. Lee, and Jie Zhan of KPNC. This project is one among many potentially high impact activities underway at Dr. Spiegelman’s Center for Methods in Implementation and Prevention Science. The study was published in the American Journal of Preventive Medicine on November 8, 2021.
By examining the electronic health records of over 2 million members of KPNC over age 50 between 2003 and 2016, the study team used a novel generalized controlled before-after study design to evaluate trends and assess the causal impact of the ACA on colorectal cancer cases and deaths in the periods before and after the 2010 ACA enactment (see PDF of Figure 1 in left sidebar). The researchers found that the enactment of the ACA was associated with a significant 23% reduction in colorectal cancer cases and deaths. Additionally, the researchers found that KPNC plan members who previously faced out-of-pocket costs for screening before the ACA showed improved colorectal cancer outcomes compared to individuals who never had out-of-pocket costs for screening. “Modern causal inference methods are powerful tools for assessing the impacts of policy changes intended to improve health and social welfare,” noted Dr. Spiegelman. “I am delighted that the National Institute of Health’s support of this work through the Director's Pioneer Award made it possible to conduct this study.”
Study author Dr. Reed concluded, “Basically, by the ACA’s removing or reducing the cost barrier for colorectal cancer screening, patients were less likely to receive a cancer diagnosis and less likely to die of colorectal cancer. So those are big things – it looks like the ACA essentially saved an estimated 177,102 people from cancer and 65,327 people from dying from cancer in the US. That’s huge.”