Rural-urban disparities in colonoscopies after the elimination of patient cost-sharing by the Affordable Care Act

Prev Med. 2019 Dec;129:105877. doi: 10.1016/j.ypmed.2019.105877. Epub 2019 Oct 24.


Introduction: Improving the prevention and early detection of colorectal cancer is a priority for reducing rural-urban disparities in colorectal cancer mortality. By eliminating out-of-pocket (OOP) costs for preventive colonoscopies, the Affordable Care Act (ACA) could have reduced rural-urban disparities in screening.

Methods: We used the Maine Health Data Organization All-Payer Claims Database including all commercially-insured and Medicare beneficiaries aged 50-75 between 2009 and 2012. Rural-urban commuting areas were used to classify rural/urban residence. ICD-9 and CPT codes identified colonoscopies. We summed all OOP payments per patient-day. An interrupted time series model estimated the impact of the ACA on trends in rural-urban disparities in colonoscopy rates and OOP costs.

Results: Before the ACA, colonoscopy rates were 16% lower in rural than urban areas (5.1% vs. 6.1% of enrollees annually) and median OOP costs were nearly double ($195 vs. $98). The ACA reduced median OOP payments by $94 (p = .001) initially and $4 monthly (p = .038) in rural areas, and $63 (p < .001) in urban areas. The rural-urban gap in OOP payments dropped by $4 monthly (p = .007). The ACA also reduced rural-urban disparities in colonoscopy rates (disparity decrease of 0.005 (6%) monthly, p < .001). The rural-urban gap in colonoscopy rates declined 40% relative to the pre-ACA period by December 2012.

Conclusions: The ACA was associated with significant reductions in rural-urban disparities in colonoscopies in Maine, suggesting that OOP costs are an important barrier for rural residents. Further research is needed to determine whether increased uptake, particularly in rural areas, translated into better patient outcomes for colorectal cancer.

Keywords: Affordable Care Act; Disparities; Equity; Out-of-pocket payments; Preventive services; Rurality.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Colonoscopy / statistics & numerical data*
  • Colorectal Neoplasms / diagnosis
  • Cost Sharing*
  • Early Detection of Cancer / statistics & numerical data*
  • Female
  • Humans
  • Maine
  • Male
  • Medicare / economics
  • Middle Aged
  • Patient Protection and Affordable Care Act / economics*
  • Patient Protection and Affordable Care Act / legislation & jurisprudence
  • Rural Population*
  • United States