Association for Public Policy Analysis & Management

Background: Breast cancer is the second leading cause of cancer death among women in the United States. While breast cancer screening is a recommended preventative service for the early detection and diagnosis of breast cancer, the breast cancer screening rates have been decreasing. The implementation of the Affordable Care Act (ACA) in 2014 allowed states to expand Medicaid and has improved cancer screening rates. As states have a choice on whether to expand Medicaid, and on whether to expand Medicaid using an expansion waiver, there may be implications for breast cancer screening rates.

Objective: To analyze the impact of Medicaid expansion waivers on breast cancer screening rates in the United States

Methods: The study makes use of the 2012 and 2016 Behavioral Risk Factor Surveillance System data. I classify states by expansion status: non-expansion (n=28) for states that did not expand Medicaid during the analytical period; traditional expansion (n=16) for states that expanded without a waiver; and waiver expansion (n=2) for states that expanded using a section 1115 waiver. This waiver allows adults newly eligible for Medicaid to enroll in private health plans offered through the marketplace.Five states (Alaska, Indiana, Louisiana, Montana and Pennsylvania) that expanded Medicaid after 2014 were excluded from the analysis. Further restrictions include women not aged 45 to 64 and those with income above $25000 (n=25395). I use two binary dependent variables for whether a woman: (i) had a breast cancer screening (or mammogram) and (ii) had a mammogram based on the American Cancer Society Guidelines. The coefficient of interest is on the interaction terms between expansion status and the expansion period. I make use of a difference-in-difference approach running weighted logistic regressions. I also control for demographic characteristics, health status and behavior and residential area.

Results: Among low-income women across all states, 90% had a mammogram and 57.8% had a mammogram based on recommendations. Breast cancer screening according to recommended guidelines was higher amongst women in expansion states compared to those in non-expansion states [odds ratio (OR) 1.3 (p<0.01)]. Low income women in expansion waiver states had lower odds of having a mammogram compared to women in traditional expansion states: OR 0.5 (p<0.05) times less likely to have a mammogram and OR 0.7 (p<0.05) times less likely to screen based on recommended guidelines. However, women in waiver expansion states after the implementation of the ACA had higher odds of screening for breast cancer: OR 2.3 (p<0.1).

Conclusion: Women in states that expanded Medicaid were more likely to screen for breast cancer. Women in states that expanded Medicaid using an expansion waiver were less likely to screen for breast cancer compared to women in the states that expanded Medicaid the traditional way.

Policy Implications: Traditional Medicaid expansion improves cancer screening rates amongst low income women. Therefore, states considering using expansion waivers need to consider the implications on cancer screening rates. Further research could study how other expansion waivers affect health outcomes.