Medicaid Expansion Seen Lifting Colon Cancer Screening for Low-Income People

— But not a cure-all in states boosting eligibility

by John GiverContributing Writer, MedPage Today May 6, 2023

CHICAGO — Colorectal cancer screening rates at so-called Federally Qualified Health Centers (FQHCs) in 2021 were higher in states that had accepted funding from the federal government to expand access to Medicaid compared with those that had not, a researcher said here.

But the data also suggested that Medicaid expansion didn’t eliminate all financial barriers to screening.

Testing rates at FQHCs (n=1,284) in 2021, which had seen some 6.9 million patients ages 50-74 who would be eligible for screening, were 42.1% in Medicaid expansion states versus 36.5% in non-expansion states (P<0.0001), according to Megan McLeod, MD, MS, of the University of California Los Angeles.

These percentages reflected the number of tests performed divided by the number of patients with encounters at these facilities, McLeod explained as she presented the findings here at Digestive Disease Week.

FQHCs receive funding through the federal Health Resources & Services Administration to support primary and preventive care to lower-income individuals. Approximately 29 million people currently receive care at these facilities, she said. As of 2021, about 95% of those in the screening age range had incomes below 200% of the federal poverty level.

Yet states that accepted the extra federal money still showed marked disparities in testing rates by race/ethnicity and financial means, her data indicated — disparities that, with one exception, were not apparent in non-expansion states.

In expansion states, patients who were Black or Hispanic, whose first language was not English, the homeless, the uninsured, and those with incomes below 200% of the federal poverty level all had decreased screening rates.

Non-expansion states, in contrast, only showed lower rates for those who had no health insurance versus patients with some form of public or private coverage. Screening rates for Black and Hispanic patients were the same as for white patients; for lower- versus higher-income individuals; and even for the unhoused versus the housed. Of course, these rates were lower across the board than in expansion states.

The Affordable Care Act was passed in 2010; one of its key provisions, which went into effect in 2014, offered to pay states 100% of the added cost for increasing eligibility for Medicaid, as a means of extending health insurance to people who previously couldn’t afford it but also didn’t qualify for Medicaid. (The subsidies were to be phased down over time, a process set to begin now that the COVID-19 public health emergency is officially over.) However, some states refused to accept the extra money, for reasons that included the sunset provision that would make them eventually shoulder the financial responsibility, and the prospect of increased entanglement with Washington.

Notably, all but one state (Wyoming) out of the 12 rejecting expansion were in the South and Midwest, regions with historically lower uptake of colorectal cancer screening. However, the statistical modeling in the new study included adjustment for covariates.

McLeod and colleagues drew on the government’s Uniform Data System, which collects information from the FQHCs on the people served and the services provided. Just over three-quarters were in states with Medicaid expansion.

Among those ages 50-74, about 43% were men, 59% lived in cities, 18% had no insurance, and 1.7% were homeless. The median percentage of non-Hispanic white patients at FQHCs was 35%; medians for non-Hispanic Black and Hispanic patients were 9% and 17%, respectively.

One of the limitations in the analysis was that data were at the level of organizations, McLeod said. Her group is now looking at survey data from FQHC patients in hopes of learning more about what drives individuals’ decisions about colorectal cancer screening.