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Barriers to colonoscopy persist despite no-cost coverage under Affordable Care Act, study finds

Innovations in Cancer - Spring 2016


Co-Program Leader for Cancer Prevention and Control at UH Seidman Cancer Center and the Case Comprehensive Cancer Center; Professor of Medicine, Case Western Reserve University School of Medicine

Making colonoscopy available at no cost to eligible Medicare beneficiaries under the Affordable Care Act (ACA) did not increase the number of people in this target population who regularly undergo the procedure, according to a new large-scale national study from University Hospitals Seidman Cancer Center and Case Western Reserve University. Interestingly, the same analysis found that rates of routine mammography significantly increased following the ACA’s mandate for low- or no-cost screenings for Medicare recipients.

“It was long assumed that cost was a major prohibitive factor for why people didn’t get screened. So the Affordable Care Act made an effort to reduce or remove costs for several highly successful screening and recommended procedures, including mammography and colonoscopy,” says study lead author Gregory Cooper, MD, Co-Program Leader for Cancer Prevention and Control at UH Seidman Cancer Center and the Case Comprehensive Cancer Center. “This data shows that doing so still doesn’t necessarily guarantee the patients who should be screened will be. Other factors clearly play a role and need to be addressed as well.”

The research team analyzed data from a 5 percent random national sample of Medicare claims from 2009 through 2012 in people ages 70 years or older. The data set captured two years of claims prior to the ACA, when authors estimate only one-third of beneficiaries could obtain screenings with little or no out-ofpocket cost, and two years of claims post-ACA implementation, when all beneficiaries were able to receive these services with no out-of-pocket cost. For mammography, the sample included 862,267 women. For colonoscopy, the sample comprised 326,503 individuals, all with one or more increased risk factors for colorectal cancer.

The study, which will appear in the May 2016 (e-published December 6) edition of the Journal of the National Cancer Institute, found a greater uptake in colonoscopy for patients who participated in a yearly wellness visit with their primary care physician. The authors hypothesize this could be because these preventive visits include a required written screening schedule for five to 10 years, and may be effectively facilitating referrals for these tests.

“This study reinforces that we need to do more than simply issue national guidelines for colorectal cancer screenings and make them affordable for everyone in the target population, especially African-Americans,” Dr. Cooper says. “It is imperative we find a way to increase participation in these important cancer screenings for at-risk populations. For example, if more people had yearly preventive visits, primary care physicians would have additional opportunities to emphasize the importance of procedures such as colonoscopy at detecting and treating cancer early.”

For more information, contact Dr. Cooper at You can view the study abstract online at


This reseach was supported, in part, by funding from the National Institutes of Health to Case Western Reserve University School of Medicine.