Colorectal Cancer Screening in a Nationwide High-deductible Health Plan Before and After the Affordable Care Act

Abstract

Background: Little is known about the effect of the Affordable Care Act’s (ACA) elimination of out-of-pocket costs for preventive services. This policy likely reduced out-of-pocket colonoscopy costs most for high-deductible health plan (HDHP) members. Objectives: Determine the ACA’s impact on colorectal cancer screening among HDHP members. Research Design: Pre-post with comparison group, constructed before and after the ACA. Subjects: We studied 2003–2012 administrative claims data of a large national health insurer. HDHP members had 1 year of low-deductible (≤$500) plan enrollment followed by 1 year of HDHP (≥$1000) enrollment after an employer-mandated switch; HDHP enrollment occurred fully after the ACA for 21,605 members and fully before the ACA for 106,609 members. We propensity score-matched contemporaneous low-deductible (≤$500) control group members to both the before-ACA and after-ACA HDHP groups. We examined the 1-year impact of the HDHP switch separately in the before-ACA and after-ACA study cohorts, then compared these changes to estimate ACA effects. Measures: Overall colorectal cancer screening, colonoscopy, and fecal-occult blood testing annual rates. Results: Before the ACA, colorectal cancer screening tests declined by 37/10,000 (−71, −4) among HDHP members versus controls; after the ACA, HDHP members experienced a nonsignificant increase in screening [+52/10,000 (−19,124)]. Corresponding changes in colonoscopy were −55/10,000 (−81, −29) before and +20/10,000 (−38, 78) after the ACA. Thus, the ACA was associated with increased colorectal cancer screening rates [+89/10,000 (11, 168); relative: +9.1% (0.5–17.8)] and screening colonoscopies [+75/10,000 (12–139); relative: +16.4% (2.5–30.3)] among HDHP members. Conclusion: The ACA was associated with improved colorectal cancer screening among HDHP members.