Cancer doesn’t play favorites. Yet, American Indian and Alaska Native (AI/AN) women are nearly twice as likely to develop cervical cancer compared to White women and up to four times as likely to die from it. Not only are AI/AN women diagnosed at more advanced stages of cervical cancer, they also have reduced access to adequate treatments once diagnosed. Despite the ability to prevent cervical cancer through screening (i.e., pap smear and HPV testing), AI/AN communities continue to experience high levels of cervical cancer diagnosis and death. This suggests that AI/AN people experience significant barriers to timely screening and treatment.
The U.S. Patient Protection and Affordable Care Act’s (ACA) Medicaid expansions began in 2014. Among expansion states, Medicaid became available to adults with incomes below 138% of the federal poverty level, providing the potential to minimize some cost-related barriers to screening. Because many AI/AN live at or below 138% of poverty level, the increase in Medicaid coverage could allow those living in expansion states to access screening services and doctors that are otherwise unavailable.
But the health care context for many AI/AN is complicated. The Indian Health Service (IHS) provides limited health services with no out-of-pocket costs to select AI/AN people. Importantly, these services aren’t “free” because AI/AN people have already paid an ultimate price through the systematic dispossession of their homelands. This formal exchange between Tribes and the U.S. Federal Government is referred to as trust responsibility. The IHS is the chronically underfunded institution that upholds the health component of this trust responsibility. The ACA’s Medicaid expansions has the potential to bring additional revenue and improved medical services to AI/AN communities, especially those with IHS access.
Our team estimated the impact of the ACA’s Medicaid expansions on cervical cancer screening among AI/AN and White women. Our hypothesis was that both groups would experience an increase in cervical cancer screening due to increases in insurance coverage. However, we thought the increase would be greater for AI/AN women because of the added opportunity for IHS Medicaid reimbursement.
While cervical cancer itself does not discriminate, access to good screening and treatment makes a world of difference.
Using Behavioral Risk Factor Surveillance System data from 2010 to 2020, we included responses from AI/AN and White Medicaid-eligible women. We analyzed responses to estimate an association between the Medicaid expansions and cervical cancer screening. We also looked at health insurance coverage and a measure of avoiding healthcare visits due to cost-related barriers.
Recommended cervical cancer screenings among AI/AN women in expansion states decreased by 1% and increased by 3% among White women. Among White women, there was also an increase in the occurrence of pap smear tests within that last 5 years.
We also observed increases in health care coverage in states that expanded Medicaid. For example, among AI/AN and White women, respectively, those residing in Medicaid expansion states experienced a 5 and 11% increase in having a health plan. Moreover, AI/AN women experienced an 8% decrease in avoiding medical care due to costs, while White women experienced a 6% decrease in this measure.
Our results suggest that the impact of Medicaid coverage expansion was similar for AI/AN and White women, despite there being an additional way for AI/AN to experience greater gains from the expansions. A comprehensive understanding of the impacts the ACA has had on AI/AN health is still being investigated. These findings make an important contribution by focusing on screening and health care coverage among AI/AN people, a group often excluded from research.
While we recognize that the Medicaid expansions have increased insurance coverage in AI/AN communities, solutions that reach beyond Medicaid are needed to address the disproportionate impact of cervical cancer among AI/AN people. Additional investments could address barriers related to inadequate transportation, long distances to services, and childcare demands. Health care systems might also automate follow-ups after positive screenings, increasingly promote routine wellness visits, and incorporate culturally responsive practices that encourage timely screening and prevention.
While cervical cancer itself does not discriminate, access to good screening and treatment makes a world of difference.
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