Do Mandates Help Reduce Disparities? Evidence from Colorectal Cancer Screening Mandates

Colorectal cancer (CRC) is the third leading cause of cancer death in the United States and survival rates among early stage diagnosis is greater than 90 percent. Racial differences in CRC screening, incidence, and mortality rates have been well documented in the previous literature. Less is known about why these disparities persist. Racial disparities may be reflective of institutional differences in health insurance coverage and generosity across races, in which case we would expect insurance mandates to reduce disparities in the insured population. On the other hand, disparities may be reflective of differences in the price elasticity of demand for screening across races. In this case, we would expect to see racial disparities even if costs for screening are equal across races. In this study, we examine response to a 2001 Medicare expansion of coverage for colonoscopy and state level mandates for CRC screening coverage introduced between 1998 and 2008. The Medicare policy represents a reasonable homogeneous price change in CRC screening that can be used to test for differences in the price elasticity of demand for colonoscopy across races. The state mandates operate in the private insurance market and likely had heterogeneous price effects across racial groups. If inequity in insurance coverage is an important determinant of racial screening disparities, state mandates should lead to a reduction in disparities. Thus, by comparing mandate effects on CRC screening among the Medicare population and among the younger population, we can disentangle the extent to which racial differences in  the price elasticity of demand for screening and racial inequalities in access to care and insurance coverage explain screening disparities. This work will help to predict likely effects of the Patient Protection and Affordable Care Act mandate for first dollar CRC screening coverage introduced in 2010 and determine whether disparities are likely to persist even when the mandate becomes binding for all plans.