Decomposing socioeconomic disparities in the use of colonoscopy among the insured elderly population before and after th
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ORIGINAL PAPER
Decomposing socioeconomic disparities in the use of colonoscopy among the insured elderly population before and after the Affordable Care Act Minjee Lee1,2 · M. Mahmud Khan3 · Heather M. Brandt4 · Ramzi G. Salloum5 · Brain Chen6 Received: 10 March 2020 / Accepted: 22 August 2020 © Springer Nature Switzerland AG 2020
Abstract Background Out-of-pocket costs may significantly dampen patients’ willingness to adopt preventive procedures. This is especially true for colonoscopies, which typically involved relatively high cost-sharing requirements prior to the Affordable Care Act (ACA) implementation in 2011. Purpose We aim to examine the effects of income-related disparities in colonoscopy use in the years prior to and immediately after the implementation of the ACA. Further, we quantify the contributions of different factors in explaining the disparities in the use of colonoscopies among elderly population with health insurance coverage. Methods Five cycles (2008, 2010, 2012, 2014, and 2016) of Behavioral Risk Factor Surveillance System data were utilized. To examine income-related disparities in the use of CRC, individuals aged 65–75 were included, and the concentration index (CI) was calculated before and after the implementation of ACA. To identify and quantify the contribution of different factors, a decomposition analysis of CI was conducted. Results CIs decreased from 0.1935 in pre-ACA years to 0.1813 in the post-ACA years among the elderly, indicating that the disparities in the use of colonoscopy was relatively low and the disparities index declined after the implementation of ACA. Decomposition analyses showed that whereas decreases in disparities derived largely from income and educational level, higher level of income and educational attainment were major contributors to the observed disparities in colonoscopy use. Conclusions Our findings indicate that the ACA’s removal of financial barriers may have contributed toward the reduction in disparities of colonoscopy use. More direct interventions, e.g., improved knowledge, better access and lower indirect cost will be helpful in improving screening among low-income and low-educational attainment households. Keywords Colonoscopy · Disparities · Concentration index · Decomposition * Minjee Lee [email protected] 1
Department of Population Science and Policy, Southern Illinois University School of Medicine, Springfield, IL, USA
2
Simons Cancer Institute, Southern Illinois University School of Medicine, Springfield, IL, USA
3
Department of Health Policy and Management, College of Public Health, University of Georgia, Athens, GA, USA
4
Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
5
Department of Health Outcomes & Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, USA
6
Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC,
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