Capsule Commentary on Richman et al., Colorectal Cancer Screening in the Era of the Affordable Care Act

The Affordable Care Act (ACA) included provisions that eliminated cost-sharing for preventive services recommended by the United States Preventive Services Task Force. In this issue of JGIM, Richland et al. present a timely assessment of how these changes in cost-sharing impacted colorectal cancer screening rates for Medicare beneficiaries.¹ Using four years of self-reported data, the authors found that overall, the rate of colorectal screening has not changed. Still, they did find a modest but statistically significant increase in the screening rate among those with Medicare only (i.e., no private insurance) and those with income < 125 % of the federal poverty level.

Although the ultimate goal of the ACA provisions is to increase use of evidence-based preventive care, they can’t work unless patients understand their plan benefit structure. The authors note a recent survey conducted by the Kaiser Family Foundation in 2014, which found that only 43 % of Americans were aware that cost-sharing had been eliminated for these preventive services.² It is likely that at the time of the Richland study, which used data through 2012, even fewer beneficiaries understood these cost-sharing exemptions. Limited consumer understanding of benefit likely limits the effectiveness of these types of policies in achieving their desired effect.

Previous surveys have found that consumers in commercial health plans with similar cost-sharing exemptions for preventive services had limited knowledge of which services were subject to cost-sharing and frequently reported avoiding free preventive services care because of cost.^3,4 When designing policies to promote use of certain services, it is important for policy makers to consider the trade-off between plan complexity and potential consumer confusion over benefits. The added complexity of exemptions can result in more confusion and misunderstanding over cost-sharing for all services. Policies that use differential cost-sharing by service should combine these changes with effective communication about plan benefits. To minimize potential confusion, the ACA did require that consumers receive a summary of benefits and coverage that is consistent across plans and ultimately easier for patients to understand. Nonetheless, results by Richland et al. suggest that more effective education and consumer decision support may be needed.