More women get mammograms when insurance picks up the entire tab, but requiring patients to bear some of the cost—in the form of copayments, deductibles or coinsurance—causes many of them to avoid or delay obtaining mammograms and other preventative care.

Even small copayments of $20 were associated with up to an 11 percent reduction in rates of breast cancer screening, researchers have found.

The Affordable Care Act (ACA) eliminated cost sharing for higher value preventative care, such as mammography screening, in an attempt to increase screening rates. Consistent annual screening is crucial in aiming to detect breast cancer as early as possible, because the disease is the second leading cause of cancer-related death among women. The U.S. Preventive Services Task Force recommends that women ages 50 to 74 undergo a screening mammography every two years.

According to a new study in the New England Journal of Medicine. researchers from Brown University’s School of Public Health and the Providence, R.I., Veterans Affairs Medical Center reviewed biennial screening mammography after enactment of the ACA to see if the elimination of cost sharing had an impact on mammography rates. They found that the screening mammography rates increased about 6 percent in the plans that had eliminated cost sharing.

They studied 15,085 women ages 65 to 74 in 24 Medicare Advantage plans that eliminated cost sharing for mammography in accordance with the ACA, compared with 52,035 women in 48 matching Medicare advantage plans that had always covered screening fully.

“Out-of-pocket costs can be a potent barrier to receiving recommended preventive care,” said lead author Amal N. Trivedi, MD, an associate professor of health services, policy and practice, and an associate professor of medicine at Brown University. “The study showed that making mammograms free led to an increase in their use. That is good for public health.”

Also See: NCI study to compare 2D and 3D mammography

Out of pocket healthcare costs disproportionately affect women. Of the 44 preventative services recommended by USPSTF, fully 26 apply specifically to women; none apply specifically to men.

However, the post-ACA increases in screening rates were found mainly among more educated women. Women living in areas where there were lower education levels and Hispanic women were less responsive to the 24 plans’ cost-sharing reduction. The study authors suggested that these populations were less likely to be aware of the ACA and its elimination of cost sharing for mammograms.

They recommended outreach to socioeconomically vulnerable and Hispanic populations to educate them about this change in insurance. “Otherwise, such strategies may paradoxically increase disparities if affluent and better-educated patients are more likely to understand and respond to them,” the researchers said.

The study authors also expressed concern that simply offering screenings for free was by itself not a sufficient incentive for women to obtain them. Even when screenings were historically fully covered by insurance, only about 73 percent of eligible women were receiving them; the screening rate for plans that had eliminated copayments was even lower, at about 65 percent.

The authors additionally worried about the effect of any repeal of the ACA on preventative care. “If the cost-sharing provisions of the ACA are rescinded, our results raise concern that fewer older women will receive recommended breast cancer screening,” they warned.

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