Amy Monahan

Despite the Affordable Care Act’s fifteen-year-old mandate for full coverage of preventive care, potentially life-saving cancer screenings remain persistently underutilized. In Can Legal Knowledge Save Lives? A Randomized Experiment in Preventive Health Screenings, Professors Christopher Robertson and Wendy Netter Epstein delve into this critical health policy puzzle and present the results of a survey that aims to uncover the extent to which ignorance about the legal requirement for free preventive care contributes to underutilization and whether experience with medical debt might also play a role.

The literature has long established that individuals in the United States receive recommended cancer screenings at suboptimal rates and that cost concerns play a role in that outcome. The ACA’s preventive care mandate was explicitly designed to address this piece of suboptimal utilization by removing cost from the equation. It is doubtful that free coverage would entirely remove barriers to care, as the screenings themselves often come with some discomfort and inconveniences. Yet, it is crucial for lawmakers and health policy stakeholders to understand whether and to what extent law can help move patients toward optimal utilization by examining the extent to which individuals covered by health insurance actually understand the coverage terms that might influence their care decisions.

Robertson and Epstein’s experiment is designed to test two distinct hypotheses. First, that informing insured individuals who have not received at least one recommended cancer screening that such screenings are not only recommended but free of charge will increase their likelihood of undertaking the screening and, second, that individuals with current or past medical debt will be less likely to pursue missed cancer screenings if they are first primed to think about their medical debt before indicating their willingness to seek out screening. Robertson and Epstein ultimately found that a “free care disclosure”—informing individuals that most plans cover breast, cervical, and colorectal cancer screenings in full with no patient cost sharing—increased the likelihood of taking steps toward screening by five percentage points, from 42% to 47%. While the overall numbers may appear modest, a population-wide increase of 5% in recommended cancer screenings could lead to significant gains in cancer survival. Interestingly, medical debt priming did not influence screening behavior, and that result held at all levels of medical debt.

The survey was limited to moderate income individuals with health insurance coverage who, based on age and sex, were eligible for colorectal, breast, or cervical cancer screenings but had not received at least one of those recommended screenings. Participants were randomly assigned to one of two main treatment groups to investigate whether fee disclosure or medical debt salience influenced the likelihood of pursuing recommended cancer screening. In the first treatment group, half of the respondents were informed that the ACA provides that, for most plans, these cancer screenings must be covered in full by the health insurer. The other half of this group received no information on the preventive care mandate. Both groups were asked whether they would like a link to assist them in obtaining the recommended screening, which was the main outcome measure for the study. In the second treatment group, half of the respondents were first asked various questions about their own medical debt history before being asked whether they would like the screening link. The other half of this group was asked about their medical debt only after they had indicated their desire to take a step toward screening by requesting the link, with the idea being that priming an individual to think about medical debt might influence their willingness to interact with the health care system for discretionary care. Respondents in both treatment groups were also asked various survey questions about their reasons for not previously getting a recommended cancer screening and their attitudes toward the health care system.

The primary finding of the experiment, that fee disclosure can meaningfully increase the likelihood of pursuing cancer screening, suggests that such disclosures could be a meaningful policy intervention if broadly implemented. But, as the authors acknowledge, doing so is more difficult than it might appear. Disclosing fee information is complex for a number of reasons, even with something as relatively straight forward as routine cancer screenings. First, not all forms of health insurance are subject to the preventive care mandate, so a blanket statement that such services are covered in full will be inaccurate. And being informed that “most” plans must cover these services in full may not be sufficient to overcome genuine cost concerns. Health plans may also place certain limitations on preventive care services, including not only network requirements but also restrictions on the scope of the screening itself, such as covering only traditional mammography and not 3D/digital breast tomosynthesis imaging. In addition, as Robertson and Epstein’s survey reveals, one of the top reasons that individuals forgo recommended screenings in the first place is not just the cost of the screening itself, but also the cost of any necessary follow-up care. For example, a woman who receives abnormal mammogram findings might be told to follow up with either an ultrasound or biopsy. But those services would be diagnostic in nature rather than preventive, which means they would be subject to the plan’s ordinary cost-sharing rules. One stark finding from the survey is that 80% of participants agreed with the statement that “going to the doctor or hospital can be dangerous financially” – a finding that is perhaps not surprising given the intricacies of both legal requirements and health insurance coverage terms.

The article presents many other interesting findings in addition to those I have just highlighted and is an important contribution to the literature on medical utilization decisions and the impact that health insurance literacy has on those decisions. More broadly, this research serves as yet another important reminder of the very real costs of our health care system’s complexity.

Editors note: Reviewers choose what to review without input from Section Editors. Jotwell Health Law Section Editor Wendy Netter Epstein had no role in the editing of this article.