National Recommendations against Prostate Specific Antigen Screening versus Statewide Medicaid Expansion Initiatives: A Battle of the Titans

Abstract

Purpose:Medicaid expansion under the Patient Protection and Affordable Care Act occurred almost concurrently with 2012 U.S. Preventive Services Task Force recommendations against prostate specific antigen screening. Here the relative influence on prostate specific antigen screening rates by 2 concurrent and opposing system-level policy initiatives is investigated: improved access to care and change in clinical practice guidelines.Materials and Methods:Behavioral Risk Factor Surveillance System data from years 2012 to 2018 were analyzed for trends in self-reported prostate specific antigen screening and insurance coverage. Subanalyses included state Medicaid expansion status and respondent federal poverty level. Multivariable logistic regression was performed to evaluate factors associated with prostate specific antigen screening.Results:From 2012 to 2018 prostate specific antigen screening predominantly declined with a notable exception of an increase of 7.3% for men at <138% federal poverty level between 2011 and 2013 in early expansion states. Initial increases did not continue, and screening trends mirrored those of nonexpansion states by 2018. Notably, 2014 planned expansions states did not follow this trend with minimal change between 2015 and 2017 compared to declines in early expansion states and nonexpansion states (-0.4% vs -6.7% and -8.6%, respectively).Conclusions:Medicaid expansion was associated with increased rates of insured men at <138% federal poverty level from 2012 to 2018 in early expansion states. In this group, initial increases in prostate specific antigen screening were not durable and followed the trend of reduced screening seen across the United States. In planned expansions states the global drop in prostate specific antigen screening from 2016 to 2018 was offset in men at <138% federal poverty level by expanding access to care. Nonexpansion states showed a steady decline in prostate specific antigen screening rates. This suggests that policy such as U.S. Preventive Services Task Force recommendations against screening competes with and often outmatches access to care.

Medicaid Expansions: Probing Medicaid’s Filling of the Cancer Genetic Testing and Screening Space

“…The majority of state Medicaid plans have HBOC policies that adhere to NCCN criteria, but Medicaid concordance rates in a related area, anticancer therapy, have been noted to be around 47.5%, with less concordance for African American and Latino prostate cancer treatment [ 59 ]. The truth for male BRCA1/2 genetic counseling and testing coverage may lie in between given USPTF’s conservative stance on another test—prostate-specific antigen [ 60 ].…”

Long-Term Impact of Medicaid Expansion on Prostate Cancer Screening

“…Notably, there were no significant changes in PSA screening rates in early expansion states from 2012 to 2014, which is different from previous shortterm studies suggesting a significant increase in PSA screening in this group. 10,11 However, these previous studies identified men in a different age range, 40 to 64 years old. Regardless, these contrasting findings cannot be attributed to the age range differences or expansion status alone.…”

“…Previous studies found short-term increases in PSA-based PCa screening among low-income men in early expansion states. 10,11 To build on these studies, we examined the longterm association of Medicaid expansion on PCa screening among low-income, childless men ages 55 to 64.…”