Influence of Insurance Coverage on Preventive Screenings
The insurance coverage expansions under healthcare reform will significantly increase the use of preventive services. Insurance coverage encourages greater use of preventive screenings and services, primarily by reducing financial barriers and facilitating access to a regular provider or usual source of care. A recent analysis by the Centers for Disease Control and Prevention found that the percentage of people who receive screening for breast, cervical, and colorectal cancer is far below national targets, and the shortfall is especially high among uninsured adults. Analysis of The Commonwealth Fund Biennial Health Insurance Survey of 2010 also demonstrates that nonelderly adults without health insurance coverage are less likely to receive a set of recommended preventive services and screening tests, including blood pressure and cholesterol checks, Papanicolaou (Pap) tests, colon cancer screening, and mammography (Table).
Table. Receipt of Preventive Services by Insurance Status Among Persons Aged 19-64 Years
| Insurance Status | |||
|---|---|---|---|
| Total | Uninsured Anytime | Insured All Year | |
| Unweighted (n) | 3033 | 827 | 2206 |
| Total (millions) | 183,594 | 51,934 | 131,661 |
| Percent distribution | 100% | 27% | 73% |
| Preventive Care | |||
| Blood pressure checked in past year | 86% | 78% | 91% |
| Received mammogram in past 2 years (women aged ≥50 years) | 73% | 47% | 78% |
| Received Pap test in past year (women aged 19-29 years); in past 3 years (age ≥30 years) | 74% | 62% | 79% |
| Received colon cancer screening in past 5 years (age ≥50 years) | 54% | 39% | 57% |
| Cholesterol checked in past 5 years | 73% | 61% | 78% |
| Received all preventive screenings | 50% | 34% | 56% |
Adjusted for age, sex, race, poverty, and health status.
Includes Pap test in the past year for women aged 19-29 years or in the past 3 years for those aged ≥30 years; colon cancer screening in the past 5 years for adults aged 50-64 years; mammography in the past 2 years for women aged 50-64 years; blood pressure checked in the past year; and cholesterol checked in the past 5 years (or in the past year if the patient has hypertension or heart disease).
Significant difference compared with insured all year (P < .05).
Only 34% of nonelderly adults without health insurance coverage were up to date on a set of recommended preventive screenings, compared with 56% of insured nonelderly adults. In particular, according to the survey:
78% of uninsured adults reported that their blood pressure had been checked in the past year, compared with 91% of adults who were insured all year;
Just 61% of uninsured adults reported that their cholesterol had been checked in the past 5 years (or in the past year for those with hypertension or heart disease), compared with more than 78% who were insured all year;
Among women aged 50-64 years who were uninsured during the year, only 47% had received a mammogram in the past 2 years, in contrast to the 78% of women who had coverage all year; and
In the recommended period, only 62% of uninsured women had Pap tests, compared with 79% of women who were insured all year.
All differences in the receipt of preventive services are statistically significant when uninsured and insured nonelderly adults are compared.
Removing Financial Barriers to Preventive Services
This estimate is clearly conservative, as several provisions in the Affordable Care Act ensure that insurance coverage specifically addresses financial barriers related to preventive care. In particular, 3 provisions of the law pertaining to Medicare and Medicaid beneficiaries, as well as privately insured persons, eliminate cost-sharing (co-insurance, deductibles, and copayments) for approved preventive services. A state, health plan, or issuer (except "grandfathered" plans) may not impose cost-sharing requirements for approved preventive services that are assigned a rating of A or B by the US Preventive Services Task Force, a panel of medical experts that advises the government. Generally, preventive immunizations, screening tests (such as colorectal cancer screening, mammography, and Pap tests), and appropriate therapy for all adults and children are covered. Additional preventive screenings and services for women and children will be covered with no cost-sharing; these include anemia screening for pregnant women and developmental screening for children younger than 3 years of age.
In addition to eliminating cost-sharing for approved preventive services, the Affordable Care Act requires Medicare to cover a new benefit: a free annual wellness visit, during which each beneficiary will receive a personalized prevention plan that includes a personalized health risk assessment, a review of personal and family medical history, and screening for cognitive impairment. On the basis of this assessment, the patient will receive a 5- to 10-year plan for pertinent screenings and preventive services. In addition, the patient will be given advice and referrals for community-based services to assist with smoking cessation, nutrition, and weight loss.
The effects of eliminating cost-sharing for preventive services will probably be significant. Previous studies suggest that full coverage of preventive services with no patient cost-sharing significantly increases use of preventive screening services. Conversely, even small incremental changes in copayments have a substantial negative effect on affordability and utilization, especially for low-income patients.
However, broader insurance coverage and reduced financial barriers alone are not enough to achieve adequate utilization of preventive services. Currently, only about one half of insured nonelderly adults in the United States report receiving a set of recommended preventive screenings. Attention must be paid to the best organizational models to reliably deliver preventive services.