Colorectal Cancer Screening and State Health Insurance Mandates

Published in: Health Economics, v. 25, no. 2, Feb. 2016, p. 178-191

Posted on RAND.org on April 25, 2016

by Mary K. Hamman, Kandice A. Kapinos

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Research Question

  1. Did rates of colorectal cancer screening change among insured adults age 51 to 64 when states required private insurance companies to cover screening services?

Colorectal cancer (CRC) is the third most deadly cancer in the USA. CRC screening is the most effective way to prevent CRC death, but compliance with recommended screenings is very low. In this study, we investigate whether CRC screening behavior changed under state mandated private insurance coverage of CRC screening in a sample of insured adults from the 1997 to 2008 Behavioral Risk Factor Surveillance Survey (BRFSS). We present difference-in-difference-in-differences (DDD) estimates that compare insured individuals age 51 to 64 to Medicare age-eligible individuals (ages 66 to 75) in mandate and non-mandate states over time. Our DDD estimates suggest endoscopic screening among men increased by 2 to 3 percentage points under mandated coverage among 51 to 64 year olds relative to their Medicare age-eligible counterparts. We find no clear evidence of changes in screening behavior among women. DD estimates suggest no evidence of a mandate effect on either type of CRC screening for men or women. Copyright © 2014 John Wiley & Sons, Ltd.

Key Findings

  • Across all states, the proportion of insured adults screened by endoscopy (colonoscopy or flexibly sigmoidoscopy) rose from 12 to 18 percent between 1997 and 2008.
  • Half of the increase (2 to 3 percentage points) for men can be explained by state mandated coverage.
  • Excluding the years prior to 2001, when Medicare expanded coverage for endoscopies, researchers estimate the state mandates increased endoscopic screening by 4.8 percentage points.
  • Endoscopic screening rates for women did not change as a result of the mandate.
  • The proportion of insured adults screened by a blood stool test declined from 21 to 14 percent between 2001 and 2008, but this decline cannot be explained by the state mandates.

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