Do State Coverage Mandates for Preventive Cancer Screenings Change Behavior?

The Affordable Care Act (ACA) of 2010 includes specific provisions to require coverage of several preventive cancer screenings. Although ACA introduces a seemingly dramatic change, in many cases, the federal mandate is preceded by state laws requiring coverage. Using 1997-2008 Medical Expenditure Panel Survey (MEPS) supplemented by the Area Resource Files (ARF), this paper seeks to understand the association between state-mandated benefits and utilization of several preventive cancer screenings (colorectal, cervical and prostate), and the induced redistributive effects among consumers, with an emphasis on how non-price barriers relate to probability of screenings. We further contributed to the field by providing estimates of redistribution of income from nonusers to users due to the barriers. This is a novel study to reveal if mandatory coverage of preventive care is a wise use of limited resources that results in positive net benefits to consumers.

The variations in the timing of mandates provided a natural experimental design for the study. A Difference-in-Difference model is paired with this design to estimate the change in utilization of preventive screenings because of state mandated benefits. The sample consists of privately insured adults with age and gender specific to the American Cancer Society (ACS) guidelines. We excludes people who are enrolled in Medicare or Medicaid any month during the survey year, as mandated benefits generally aim at private insurance. Those who reported a diagnosis of cervical, colon and prostate cancers are excluded from the respective sample. For each of the cancer screening, I used a binary Logit model weighted by MEPS personal weights. The treatment group is based on existence of mandates in states. Post-mandated periods represent the timing when people were surveyed in a year after the residency state adopted the mandates. The outcome variables represent the probability of individual receiving a given cancer screening. Explanatory variables characterized the demographics, socio-economic status of individuals and their barriers to health care, as well as local physician availability.

State mandates do not statistically change the utilization of any cancer screenings, across different subgroups.  ERISA exemption for self-insured health plans did not explain away such null effects. Several non-price factors strongly predict that screening users are those with more education attainment, higher income levels, not being an Asian, having a usual place of care, living in urban areas with proficient English, and having adequate physician supply.

The price of preventive cancer screenings paid by insurance plans is taken to be the national averaged insurer paid price of the interested services. It is shown that each individual who is eligible to use the service but have forgone it due to other barriers, potentially subsidize the users by $403 over five years. While the mandates are ineffective in increasing cancer screening levels, such legislations are found to be regressive and have introduced redistribution of incomes from the disadvantaged non-users to the well-off users. Some non-price social determinants are associated with large regressive effects, including being Asian, less educated, lack of usual source of care and English proficiency.