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. 2015 Jul;105 Suppl 3(Suppl 3):S508-16.
doi: 10.2105/AJPH.2015.302578. Epub 2015 Apr 23.

Mandated coverage of preventive care and reduction in disparities: evidence from colorectal cancer screening

Mary K Hamman  1 , Kandice A Kapinos
Affiliations

Mandated coverage of preventive care and reduction in disparities: evidence from colorectal cancer screening

Mary K Hamman et al. Am J Public Health. 2015 Jul.

Abstract

Objectives: We identified correlates of racial/ethnic disparities in colorectal cancer screening and changes in disparities under state-mandated insurance coverage.

Methods: Using Behavioral Risk Factor Surveillance System data, we estimated a Fairlie decomposition in the insured population aged 50 to 64 years and a regression-adjusted difference-in-difference-in-difference model of changes in screening attributable to mandates.

Results: Under mandated coverage, blood stool test (BST) rates increased among Black, Asian, and Native American men, but rates among Whites also increased, so disparities did not change. Endoscopic screening rates increased by 10 percentage points for Hispanic men and 3 percentage points for non-Hispanic men. BST rates fell among Hispanic relative to non-Hispanic men. We found no changes for women. However, endoscopic screening rates improved among lower income individuals across all races and ethnicities.

Conclusions: Mandates were associated with a reduction in endoscopic screening disparities only for Hispanic men but may indirectly reduce racial/ethnic disparities by increasing rates among lower income individuals. Findings imply that systematic differences in insurance coverage, or health plan fragmentation, likely existed without mandates. These findings underscore the need to research disparities within insured populations.

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Figures

FIGURE 1—
FIGURE 1—
Triple difference estimates of changes in screening rates under mandated coverage by race/ethnicity for (a) up-to-date men, (b) up-to-date women, (c) endoscopy in men, (d) endoscopy in women, (e) bowel screening test in men, and (f) bowel screening test in women: Behavioral Risk Factor Surveillance System, United States, 2002–2008. Note. Bars depict changes in screening rates (as decimals) under mandated coverage on the basis of logit estimation of the triple difference model. Estimates were derived using the margins command in Stata version 12.0 for racial and ethnic group. Whiskers indicate 95% confidence intervals.
FIGURE 2—
FIGURE 2—
Triple difference estimates of changes in screening rates by household income for (a) endoscopy in men, (b) endoscopy in women, (c) bowel screening test in men, and (d) bowel screening test in women: Behavioral Risk Factor Surveillance System, United States, 2002–2008. Note. Points depict changes in screening rates (as decimals) under mandated coverage on the basis of logit estimation of the triple difference model. Estimates were derived using the margins command in Stata version 12.0 at each value of the categorical household income variable. Whiskers indicate 95% confidence intervals.
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