Panel Paper: The Impact of Universal Coverage On Breast and Cervical Cancer Screening: Evidence From Massachusetts

Friday, November 9, 2012 : 2:00 PM
Pratt B (Sheraton Baltimore City Center Hotel)

*Names in bold indicate Presenter

Lindsay Sabik and Cathy Bradley, Virginia Commonwealth University

There are approximately 230,000 new cases of and 40,000 deaths from breast cancer each year, as well as 12,000 new cases of and 4,000 deaths from cervical cancer among US women.  While mortality rates have fallen over recent decades due to improved screening and treatment, breast cancer remains a leading cause of cancer death among US women.  For both breast and cervical cancer, there are disparities in diagnosis and treatment by income, race and ethnicity, and insurance status.  In an effort to increase early detection among low-income, uninsured women, the Centers for Disease Control and Prevention introduced the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) in the 1990’s, offering free screening to eligible women.  Despite increasing screening among low-income women, the program was unable to reach many eligible women and prior research shows that disparities by income, insurance, and ethnicity remain.  Health reform in Massachusetts, implemented in 2006, expanded health insurance coverage to nearly all residents of the state, and may have increased screening more than a stand-alone targeted program.  This paper investigates how the implementation of near-universal coverage in Massachusetts affected breast and cervical cancer screening overall, among low-income women (including those previously eligible for screening through the NBCCEDP), and among racial and ethnic minorities.

We use data from the Behavioral Risk Factor Surveillance System between 2001 and 2010 to consider receipt of mammograms (breast cancer screening) among women ages 50 to 64 and pap smears (cervical cancer screening) among women aged 18 to 64.  We use data from six New England states to estimate difference-in-difference models comparing changes in cancer screening in Massachusetts before and after health reform to changes in other New England states over the same period.  Models control for individual covariates (age, marital status, education, employment, household income, and race) as well as state and year fixed effects.  We also consider the effect among low-income women and racial and ethnic minority women.  Preliminary results suggest a statistically significant effect of Massachusetts health reform on breast and cervical cancer screening.  The effect is strongest for cervical cancer screening.  For both breast and cervical cancer screening, the effect remains significant and is only slightly smaller in magnitude when controlling for individual health insurance coverage, suggesting the effect is driven largely by changes along the intensive margin (e.g. more generous or flexible health insurance coverage).  Further, for both outcomes, the effect is stronger 2 to 3 years after the implementation of reform than in the years immediately following, suggesting the increase is not driven primarily by pent-up demand among the previously uninsured.  Estimates from models limiting the sample to low-income or minority women are statistically insignificant for breast cancer screening, though positive and statistically significant for cervical cancer screening, with the largest effects among low-income women and smaller effects among minority women.  Overall, Massachusetts reform appears to have increased breast and cervical cancer screening, particularly among low-income women, though the effect among minority women was not as large as among other groups.