Mandated Coverage of Preventive Care and Reduction in Disparities

Evidence from Colorectal Cancer Screening

Published in: American Journal of Public Health, v. 105, no. S3, July 2015, p. S508-S516

Posted on on May 06, 2015

by Mary K. Hamman, Kandice A. Kapinos

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Research Question

  1. Does mandated coverage of colorectal cancer screening reduce racial/ethnic disparities in screening?

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.

Key Findings

  • In general, mandated coverage was associated with reduced disparities in colorectal screening.
  • But universal health care coverage may not substantially reduce disparities as long as systematic differences in plan benefits and cost sharing continue to exist.


Research on health disparities should not treat insurance coverage as a binary concept but rather assess efforts to reduce disparities in the context of the institutional complexity of health insurance coverage.

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