Policies requiring health insurers to cover evidence-based colorectal cancer (CRC) screening services may boost screening rates overall, but they can also lead to the unintended consequence of increasing racial disparities in screening compliance, according to a new PhD dissertation research study successfully defended by Michael Preston on Friday at the University of Arkansas for Medical Sciences. Michael’s research was supported by a Junior Investigator Award in Public Health Services & Systems Research from the RWJF-funded National Coordinating Center for Public Health Services & Systems Research. Michael assembled 15 years of BRFSS data from the contiguous US states to conduct this study, allowing him to observe screening behavior before and after more than 20 states passed coverage mandate laws for CRC screening at different times during 1997-2010. His data series continued through 2011-12 when the Affordable Care Act’s much stronger federal law kicked in requiring first-dollar coverage for CRC screening and closing loopholes in some state laws. Michael used a strong, quasi-experimental, difference-in-difference design to distinguish the effects of the insurance mandates from other temporal trends in screening across the states. His results offer a cautionary tale about policy change that we’ve seen before, but all too often we fail to prevent: the benefits of new programs and policies accrue disproportionately to those who are lucky enough to have the resources, information, and supports necessary to take full advantage.

The take-home message: we need to become much more adept at anticipating and counteracting these inequities as part of the policy design and implementation process. This is especially true when the capacity to implement programs and policies is constrained and unevenly distributed across states and communities. This is now the case not only with CRC screening, but also with many other components of the Affordable Care Act.

It was a privilege (and great fun) for me to mentor Michael through his dissertation experience, and to be with him back in Little Rock on Friday as he defended this important work in the PhD Program in Health Services Research at UAMS. He becomes the 5th person to complete this very special program we created back in 2006 in Arkansas—a state that is now ground zero for a number of innovative health reforms that need strong research to guide implementation. Kudos to the renown health economist Dr. Mick Tilford for advancing this PhD program and the health policy environment in Arkansas. Michael, err Dr. Preston, is finishing just in time.