Differences in Cancer Screening Responses to State Medicaid Expansions by Race and Ethnicity, 2011‒2019

Abstract

Objectives. To estimate whether state Medicaid expansions' relationships to breast, cervical, and colorectal cancer screening differ by race/ethnicity. Methods. Analyses conducted in 2021 used 2011-2016 and 2018-2019 Behavioral Risk Factor Surveillance System data on adults aged 40 to 64 years with household incomes below 400% of the federal poverty guideline (FPG; n = 537 250). Triple-difference analyses compared cancer screening in Medicaid expansion versus nonexpansion states, before versus after expansion, among people with incomes above versus below the eligibility cutoff (138% FPG). Race/ethnicity and ethnicity-by-language interaction terms tested for effect modification. Results. Associations between Medicaid expansions and cancer screening were significant for past-2-year mammograms and past-5-year colorectal screening. Effect modification analyses showed elevated mammography among non-Hispanic Asian women (+9.0 percentage points; 95% confidence interval [CI] = 3.2, 14.8) and Hispanic women (+6.0 percentage points; 95% CI = 2.0, 10.1), and Papanicolaou tests among Hispanic women (+4.2 percentage points; 95% CI = 0.1, 8.2). Findings were not limited to English- or Spanish-speaking respondents and were robust to insurance status controls. Conclusions. Medicaid expansions yielded statistically significant increases in income-eligible Asian and Hispanic women's mammography and Hispanic women's Pap testing relative to non-Hispanic White women. Neither language proficiency nor insurance status explained these findings. (Am J Public Health. 2022;112(11):1630-1639. https://doi.org/10.2105/AJPH.2022.307027).

FIGURE 1—

Screening Responses to Medicaid Expansions: United States, Behavioral Risk Factor Surveillance System, 2011–2016 and 2018–2019 Note. CI = confidence interval; Pap = Papanicolaou. Sample weighted linear probability models estimated triple-difference specifications to approximate the relationship between state Medicaid expansions and cancer screening indicators among adults without dependent children who are not age-eligible for Medicare—specifically, comparing respondents in states that did vs did not expand Medicaid, before vs after expansions, with incomes below the expanded-access cutoff (138% of the federal poverty guideline [FPG; according to the US Department of Health and Human Services]) vs at or above it but below 400% of FPG. Point estimates and 95% CIs estimated screening responses to Medicaid expansions, with the analytic sample limited to those younger than 65 years for whom the screening was recommended—that is, women aged 50–64 years for biennial mammograms, women aged 40 to 64 years for Pap tests every 3 years, and respondents aged 45–64 years for colorectal screenings (colonoscopies or sigmoidoscopies) every 5 years. See Table A (available as a supplement to the online version of this article at https://ajph.org) for output in tabular form with P values.

FIGURE 2—

Differential Screening Responses to Medicaid Expansions by Race/Ethnicity: United States, Behavioral Risk Factor Surveillance System, 2011–2016 and 2018–2019 Note. CI = confidence interval; Pap = Papanicolaou. Sample weighted linear probability models estimated triple-difference specifications to approximate the relationship between state Medicaid expansions and cancer screening indicators among adults without dependent children who are not age-eligible for Medicare—specifically, comparing respondents in states that did vs did not expand Medicaid, before vs after expansions, with incomes below the expanded-access cutoff (138% of the federal poverty guideline [FPG; according to the US Department of Health and Human Services]) vs at or above it but below 400% of FPG. Point estimates and 95% CIs plotted here estimated whether these screening responses differed by race/ethnicity, relative to the response among non-Hispanic White respondents. For each outcome, the analytic sample was limited to those younger than 65 years for whom the screening was recommended—that is, women aged 50–64 years for biennial mammograms, women aged 40–64 years for Pap tests every 3 years, and respondents aged 45–64 years for colorectal screenings (colonoscopies or sigmoidoscopies) every 5 years. See Table B (available as a supplement to the online version of this article at https://ajph.org) for output in tabular form with P values.

FIGURE 3—

Differential Screening Responses to Medicaid Expansions by Ethnicity and Survey Language: United States, Behavioral Risk Factor Surveillance System, 2011–2016 and 2018–2019 Note. CI = confidence interval; Pap = Papanicolaou. Sample weighted linear probability models estimated triple difference specifications to approximate the relationship between state Medicaid expansions and cancer screening indicators among adults without dependent children who are not age-eligible for Medicare—specifically, comparing respondents in states that did vs did not expand Medicaid, before vs after expansions, with incomes below the expanded-access cutoff (138% of the federal poverty guideline [FPG]) vs at or above it but below 400% of FPG. Point estimates and 95% CIs plotted here estimate whether these screening responses differed between Hispanic respondents who completed the survey in English, Hispanic respondents who completed the survey in Spanish, and the non-Hispanic reference group. For each outcome, the analytic sample was limited to those younger than 65 years for whom the screening was recommended—that is, women aged 50–64 years for biennial mammograms, women aged 40–64 years for Pap tests every 3 years, and respondents aged 45–64 years for colorectal screenings (colonoscopies or sigmoidoscopies) every 5 years. See Table C (available as a supplement to the online version of this article at http://ajph.org) for output in tabular form with P values.