The potential impact of the Affordable Care Act and Medicaid expansion on reducing colorectal cancer screening disparities in African American males

Autoři: Wizdom Powell aff001;  Leah Frerichs aff002;  Rachel Townsley aff003;  Maria Mayorga aff003;  Jennifer Richmond aff004;  Giselle Corbie-Smith aff005;  Stephanie Wheeler aff002;  Kristen Hassmiller Lich aff002
Působiště autorů: Health Disparities Institute and Department of Psychiatry, University of Connecticut, Farmington, CT, United States of America aff001;  Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America aff002;  Department of Industrial and Systems Engineering, North Carolina State University, Raleigh, NC, United States of America aff003;  Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America aff004;  Center for Health Equity Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America aff005;  Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America aff006;  Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America aff007
Vyšlo v časopise: PLoS ONE 15(1)
Kategorie: Research Article


Few investigations have explored the potential impact of the Affordable Care Act on health disparity outcomes in states that chose to forgo Medicaid expansion. Filling this evidence gap is pressing as Congress grapples with controversial healthcare legislation that could phase out Medicaid expansion. Colorectal cancer (CRC) is a commonly diagnosed, preventable cancer in the US that disproportionately burdens African American men and has substantial potential to be impacted by improved healthcare insurance coverage. Our objective was to estimate the impact of the Affordable Care Act (increasing insurance through health exchanges alone or with Medicaid expansion) on colorectal cancer outcomes and economic costs among African American and White males in North Carolina (NC), a state that did not expand Medicaid. We used an individual-based simulation model to estimate the impact of ACA (increasing insurance through health exchanges alone or with Medicaid expansion) on three CRC outcomes (screening, stage-specific incidence, and deaths) and economic costs among African American and White males in NC who were age-eligible for screening (between ages 50 and 75) during the study period, years of 2013–2023. Health exchanges and Medicaid expansion improved simulated CRC outcomes overall, though the impact was more substantial among AAs. Relative to health exchanges alone, Medicaid expansion would prevent between 7.1 to 25.5 CRC cases and 4.1 to 16.4 per 100,000 CRC cases among AA and White males, respectively. Our findings suggest policies that expanding affordable, quality healthcare coverage could have a demonstrable, cost-saving impact while reducing cancer disparities.

Klíčová slova:

African American people – Colorectal cancer – Health care policy – Health insurance – Health screening – Oncology – Screening guidelines – Simulation and modeling


1. Hinton E, Artiga S. Characteristics of Remaining Uninsured Men and Potential Strategies to Reach and Enroll them in Health Coverage. Kaiser Family Foundation, 2016.

2. Kaiser Family Foundation. Current Status of State Medicaid Expansion Decisions 2018 [cited 2018 February 9]. Available from:

3. Dworsky M, Eibner C. The Effect of the 2014 Medicaid Expansion on Insurance Coverage for Newly Eligible Childless Adults. RAND, 2016.

4. Sommers BD, Gunja MZ, Finegold K, Musco T. Changes in Self-reported Insurance Coverage, Access to Care, and Health Under the Affordable Care Act. Jama. 2015;314(4):366–74. Epub 2015/07/29. doi: 10.1001/jama.2015.8421 26219054.

5. Long SK, Karpman M, Shartzer A, Wissoker D, Kenney GM, Zuckerman S, et al. Taking Stock: Health Insurance Coverage under the ACA as of September 2014. Urban Institute, 2014.

6. Courtemanche C, Marton J, Ukert B, Yelowitz A, Zapata D. Early Impacts of the Affordable Care Act on Health Insurance Coverage in Medicaid Expansion and Non-Expansion States. Journal of policy analysis and management: [the journal of the Association for Public Policy Analysis and Management]. 2017;36(1):178–210. Epub 2016/12/20. doi: 10.1002/pam.21961 27992151.

7. Antonisse L, Garfield R, Rudowitz R, Artiga S. The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review. Kaiser Family Foundation, 2017.

8. Rutter CM, Zaslavsky A, Feuer E. Dynamic Microsimulation Models for Health Outcomes: A Review. Medical Decision Making. 2011;31(1):10–8. doi: 10.1177/0272989X10369005 PMC3404886. 20484091

9. Parente ST, Feldman R. Microsimulation of private health insurance and medicaid take-up following the U.S. Supreme court decision upholding the Affordable Care Act. Health Serv Res. 2013;48(2 Pt 2):826–49. Epub 2013/02/13. doi: 10.1111/1475-6773.12036 23398372; PubMed Central PMCID: PMC3626326.

10. Eibner C, Price CC. The Effect of the Affordable Care Act on Enrollment and Premiums, With and Without the Individual Mandate. Rand health quarterly. 2012;2(1):2. Epub 2012/03/01. 28083224; PubMed Central PMCID: PMC4945284.

11. Clemans-Cope L, Kenney GM, Buettgens M, Carroll C, Blavin F. The Affordable Care Act's coverage expansions will reduce differences in uninsurance rates by race and ethnicity. Health Aff (Millwood). 2012;31(5):920–30. Epub 2012/05/09. doi: 10.1377/hlthaff.2011.1086 22566430.

12. Scott JW, Neiman PU, Najjar PA, Tsai TC, Scott KW, Shrime MG, et al. Potential impact of Affordable Care Act-related insurance expansion on trauma care reimbursement. The journal of trauma and acute care surgery. 2017;82(5):887–95. Epub 2017/04/22. doi: 10.1097/TA.0000000000001400 28431415; PubMed Central PMCID: PMC5468098.

13. Peterse EFP, Meester RGS, Gini A, Doubeni CA, Anderson DS, Berger FG, et al. Value Of Waiving Coinsurance For Colorectal Cancer Screening In Medicare Beneficiaries. Health Aff (Millwood). 2017;36(12):2151–9. Epub 2017/12/05. doi: 10.1377/hlthaff.2017.0228 29200350.

14. Siegel RL, Miller KD, Fedewa SA, Ahnen DJ, Meester RGS, Barzi A, et al. Colorectal cancer statistics, 2017. CA: a cancer journal for clinicians. 2017;67(3):177–93. Epub 2017/03/02. doi: 10.3322/caac.21395 28248415.

15. National Cancer Institute. Cancer Stat Facts: Colon and Rectum Cancer 2017 [cited 2017 August 16]. Available from:

16. DeSantis CE, Siegel RL, Sauer AG, Miller KD, Fedewa SA, Alcaraz KI, et al. Cancer statistics for African Americans, 2016: Progress and opportunities in reducing racial disparities. CA: a cancer journal for clinicians. 2016;66(4):290–308. Epub 2016/02/26. doi: 10.3322/caac.21340 26910411.

17. American Cancer Society. Colorectal Cancer: Facts & Figures 2017–2019. American Cancer Society, 2017.

18. Richman I, Asch SM, Bhattacharya J, Owens DK. Colorectal Cancer Screening in the Era of the Affordable Care Act. Journal of general internal medicine. 2016;31(3):315–20. doi: 10.1007/s11606-015-3504-2 PMC4762811. 26349953

19. American Cancer Society. Colorectal Cancer Screening: Insurance Coverage 2017 [cited 2018 February 9]. Available from:

20. Office of the Assistant Secretary for Planning and Evaluation. Medicaid expansion impacts on insurance coverage and access to care. Washington, D.C: Department of Health and Human Services, 2017.

21. Hassmiller Lich K, Cornejo DA, Mayorga ME, Pignone M, Tangka FK, Richardson LC, et al. Cost-Effectiveness Analysis of Four Simulated Colorectal Cancer Screening Interventions, North Carolina. Preventing chronic disease. 2017;14:E18. Epub 2017/02/24. doi: 10.5888/pcd14.160158 28231042; PubMed Central PMCID: PMC5325466.

22. Subramanian S, Bobashev G, Morris RJ. Modeling the cost-effectiveness of colorectal cancer screening: policy guidance based on patient preferences and compliance. Cancer epidemiology, biomarkers & prevention: a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology. 2009;18(7):1971–8. Epub 2009/07/02. doi: 10.1158/1055-9965.epi-09-0083 19567507.

23. Loeve F, Boer R, van Oortmarssen GJ, van Ballegooijen M, Habbema JD. The MISCAN-COLON simulation model for the evaluation of colorectal cancer screening. Computers and biomedical research, an international journal. 1999;32(1):13–33. Epub 1999/03/06. doi: 10.1006/cbmr.1998.1498 10066353.

24. Lansdorp-Vogelaar I, van Ballegooijen M, Zauber AG, Boer R, Wilschut J, Winawer SJ, et al. Individualizing colonoscopy screening by sex and race. Gastrointestinal endoscopy. 2009;70(1):96–108, .e1-24. Epub 2009/05/27. doi: 10.1016/j.gie.2008.08.040 19467539; PubMed Central PMCID: PMC2805960.

25. Davis MM, Renfro S, Pham R, Hassmiller Lich K, Shannon J, Coronado GD, et al. Geographic and population-level disparities in colorectal cancer testing: A multilevel analysis of Medicaid and commercial claims data. Preventive medicine. 2017;101:44–52. Epub 2017/05/17. doi: 10.1016/j.ypmed.2017.05.001 28506715.

26. Wheeler SB, Kuo TM, Goyal RK, Meyer AM, Hassmiller Lich K, Gillen EM, et al. Regional variation in colorectal cancer testing and geographic availability of care in a publicly insured population. Health & place. 2014;29:114–23. Epub 2014/07/27. doi: 10.1016/j.healthplace.2014.07.001 25063908.

27. Chubak J, Garcia MP, Burnett-Hartman AN, Zheng Y, Corley DA, Halm EA, et al. Time to Colonoscopy after Positive Fecal Blood Test in Four U.S. Health Care Systems. Cancer epidemiology, biomarkers & prevention: a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology. 2016;25(2):344–50. Epub 2016/02/05. doi: 10.1158/1055-9965.epi-15-0470 26843520; PubMed Central PMCID: PMC4767632.

28. Greenspan M, Chehl N, Shawron K, Barnes L, Li H, Avery E, et al. Patient Non-adherence and Cancellations Are Higher for Screening Colonoscopy Compared with Surveillance Colonoscopy. Digestive diseases and sciences. 2015;60(10):2930–6. Epub 2015/04/24. doi: 10.1007/s10620-015-3664-2 25902746.

29. Kahn B, Freeland Z, Gopal P, Agrawal D, Mayorga CA, Mithani R, et al. Predictors of guideline concordance for surveillance colonoscopy recommendations in patients at a safety-net health system. Cancer causes & control: CCC. 2015;26(11):1653–60. Epub 2015/09/18. doi: 10.1007/s10552-015-0661-x 26376891; PubMed Central PMCID: PMC5615815.

30. Wheaton WD, Cajka JC, Chasteen BM, Wagener DK, Cooley PC, Ganapathi L, et al. Synthesized Population Databases: A US Geospatial Database for Agent-Based Models. Methods report (RTI Press). 2009;2009(10):905. doi: 10.3768/ PMC2875687. 20505787

31. Sommers BD, Kenney GM, Epstein AM. New evidence on the Affordable Care Act: coverage impacts of early medicaid expansions. Health Aff (Millwood). 2014;33(1):78–87. Epub 2014/01/08. doi: 10.1377/hlthaff.2013.1087 24395938.

32. Wheeler SB, Kuo T-M, Meyer AM, Martens CE, Hassmiller Lich KM, Tangka FKL, et al. Multilevel predictors of colorectal cancer testing modality among publicly and privately insured people turning 50. Preventive Medicine Reports. 2017;6:9–16. doi: 10.1016/j.pmedr.2016.11.019 PMC5300695. 28210537

33. Zauber AG, Lansdorp-Vogelaar I, Wilschut J, Knudsen AB, van Ballegooijen M, Kuntz KM. Cost-Effectiveness of DNA Stool Testing to Screen for Colorectal Cancer. Rockville (MD): Agency for Healthcare Research and Quality (US), 2007.

34. Haddix AC, Teutsch SM, Corso PS. Prevention effectiveness: a guide to decision analysis and economic evaluation: Oxford University Press; 2003.

35. Meester RG, Doubeni CA, Zauber AG, Goede SL, Levin TR, Corley DA, et al. Public health impact of achieving 80% colorectal cancer screening rates in the United States by 2018. Cancer. 2015;121(13):2281–5. Epub 2015/03/13. doi: 10.1002/cncr.29336 25763558; PubMed Central PMCID: PMC4567966.

36. Sommers BD, Epstein AM. U.S. governors and the Medicaid expansion—no quick resolution in sight. The New England journal of medicine. 2013;368(6):496–9. Epub 2013/01/18. doi: 10.1056/NEJMp1215785 23323866.

37. Rudowitz R. Understanding How States Access the ACA Enhanced Medicaid Match Rates Kaiser Family Foundation, 2014.

38. Dorn S, Francis N, Urban Institute, Snyder L, Rudowitz R. The Effects of the Medicaid Expansion on State Budgets: An Early Look in Select States. Kaiser Family Foundation, 2015.

39. Friedenberg FK, Singh M, George NS, Sankineni A, Shah S. Prevalence and distribution of adenomas in black Americans undergoing colorectal cancer screening. Digestive diseases and sciences. 2012;57(2):489–95. Epub 2011/11/05. doi: 10.1007/s10620-011-1952-z 22052446; PubMed Central PMCID: PMC3572739.

40. Lebwohl B, Capiak K, Neugut AI, Kastrinos F. Risk of colorectal adenomas and advanced neoplasia in Hispanic, black and white patients undergoing screening colonoscopy. Alimentary pharmacology & therapeutics. 2012;35(12):1467–73. Epub 2012/05/01. doi: 10.1111/j.1365-2036.2012.05119.x 22540887; PubMed Central PMCID: PMC3396558.

41. Schroy PC 3rd, Coe A, Chen CA, O'Brien MJ, Heeren TC. Prevalence of advanced colorectal neoplasia in white and black patients undergoing screening colonoscopy in a safety-net hospital. Annals of internal medicine. 2013;159(1):13–20. Epub 2013/07/03. doi: 10.7326/0003-4819-159-1-201307020-00004 23817700; PubMed Central PMCID: PMC4218749.

Článek vyšel v časopise


2020 Číslo 1
Nejčtenější tento týden