The Center for Health Innovation & Policy Science (CHIPS) is an interdisciplinary research center that works to improve health across communities and the lifespan through innovation, evaluation, and training in health policy and health systems science, with a focus on health equity.

DirectorDavid Grembowski, PhD

Associate DirectorLayla G. Booshehri, PhD

Policy BriefSeptember 2021

CHIPS

Health Insurance Cost Sharing A Blunt Instrument with Targeted Effects

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Victoria Bowers

Cost Sharing Defined

Deductible: The amount the beneficiary pays for healthcare services before their insurance plan starts to pay.

Copayment: A fixed amount the beneficiary pays for a healthcare service after they have met their deductible.

Coinsurance: The percentage of healthcare service costs paid by the beneficiary after they have met their deductible.

Executive Summary• Cost sharing—when health insurance beneficiaries pay a portion

of their healthcare costs through copayments, coinsurance, and deductibles—is widely used throughout the U.S. health insurance system as a method of containing the U.S.’s high healthcare expenditures, despite mixed evidence of its ability to do so.

• Research indicates an association between cost sharing and reduced healthcare access and use among beneficiaries overall, with evidence of greater harm to racial and ethnic minorities, including delayed or foregone care, reduced preventive screenings, and reduced medication adherence.

• Effects of cost sharing may have widened disparities in healthcare access and use for racial and ethnic minorities during the COVID-19 pandemic.

• Strategies to mitigate this harm include maintaining policies that waive cost sharing on an emergency basis during the COVID-19 pandemic and after it is over, expanding value-based care, addressing prices of medical services, and improving communication strategies in state and federal health insurance exchanges.

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IntroductionThroughout the U.S. health insurance system, beneficiaries are responsible for a portion of their care through cost sharing structures, such as copayments, coinsurance, and deductibles. Cost sharing is widely promoted as a method of containing U.S. healthcare expenditures1,2 despite mixed evidence of its ability to do so.3-5 Between 1974 and 1982 the RAND Health Insurance Experiment demonstrated an inverse relationship between cost sharing and health services utilization, providing evidence for the concept of “moral hazard” in healthcare—the idea that reduced cost sharing may lead to wasteful use of medical services.6

Concerns about using “moral hazard” as a basis for healthcare policy stem from RAND’s findings that cost sharing leads to worse health outcomes among low-income populations6 as well as limited research on the effects of cost sharing among racial and ethnic minorities. A growing body of evidence indicates that cost sharing may contribute to a range of unintended consequences among racial and ethnic minorities as well as low-income populations, including delayed or forgone care, reduced preventive screenings, and reduced medication adherence.

These negative effects of cost sharing exacerbate existing health disparities. The COVID-19 pandemic highlighted pre-existing disparities within the U.S. healthcare system: racial and ethnic minorities generally have lower socioeconomic status and worse baseline health conditions compared to whites yet face reduced healthcare access and use.5, 7-10 These pre-existing disparities make racial and ethnic minorities more susceptible to potential negative effects of healthcare policies. As strategies to reduce healthcare expenditures continue to be developed, policy makers should remain aware of potential unintended harm associated with cost sharing among racial and ethnic minorities.

Cost Sharing within the U.S. Health Insurance SystemSeventy percent of U.S. residents are enrolled in health insurance plans that impose cost sharing, with over half enrolled in employer-sponsored plans.11 In addition to high enrollment, cost sharing has increased over the last decade (Fig. 1).12 The average nationwide deductible in employer-sponsored insurance rose from $869 to $1,808 between 2008 and 2017,13 and the percentage of workers in employer-sponsored high-deductible health plans (HDHPs) rose from 11.4% to 46.5%

Figure 1Growth of general annual deductibles and covered workers’ wages between

2008 and 2018

Kaiser Family Foundation, October 201812

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Health insurance

literacy and cost

sharingResearch indicates that most

health insurance beneficiaries

have a difficult time

understanding their plan’s

cost sharing requirements.20,21

This so-called “health

insurance literacy” is often

lower among racial and

ethnic minorities.22 Research

indicates that limited health

insurance literacy may lead

to delayed or forgone care

because many beneficiaries

are unaware of which services

are covered by reduced or zero

cost sharing.23-25

between 2006 and 2016.14 In Traditional Medicare, 83% of beneficiaries purchase supplemental health insurance plans, such as Medigap, to cover some of their cost sharing requirements.15 While Medicaid—which covers 19.8% of U.S. residents—generally does not impose cost sharing, 22 of the 39 Medicaid-expansion states have obtained federal waivers to impose cost sharing for certain services and populations.16

The Affordable Care Act (ACA) eliminated cost sharing for preventive services under all Marketplace plans and established cost sharing reductions for individuals enrolled in silver-level plans with incomes up to 250% of the federal poverty level (FPL).17 Members of federally recognized American Indian Alaska Native tribes with incomes up to 300% of the FPL can enroll in Marketplace plans with zero cost sharing; if they receive care from an Indian Health Service provider or qualify for Medicaid, they face zero cost sharing regardless of income.18

In Washington state, 74% of health insurance beneficiaries are enrolled in plans with cost sharing, and 53% of those are enrolled in employer-sponsored plans.11 In 2019, the average deductible for an individual with employer-sponsored coverage was $1,655; in 2020, it was $3,908 for an individual with Washington Health Benefit Exchange coverage.19 Over 55,000 Washington state families are enrolled in plans with deductibles greater than $9,000.19

Acute careRacial and ethnic minorities may delay or forgo acute care services at a higher rate than whites due to cost sharing A 2021 analysis of National Health Interview Survey data indicates that among the insured population, 15% of Hispanic and 13% of Black beneficiaries delayed care in 2019 due to costs compared to 9% of white beneficiaries (Fig. 2).26

Additionally, a 2003 pilot study of federally qualified health centers in Multnomah and Washington counties in Oregon found that copayments were associated with a higher rate of missed appointments.27 Racial and ethnic minorities’ use of these centers is significantly higher than that of whites.28

Preventive careReduced or zero cost sharing may increase preventive care for racial and ethnic minorities

Colon cancer screening:When comparing the effects of zero cost sharing on colonoscopy rates among privately insured racial and ethnic minorities compared to white Medicaid beneficiaries, Hispanic and Black beneficiaries had 27% and 16% greater odds of receiving colonoscopies, respectively.29 Comparing

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pre- and post-ACA cancer screening rates among privately insured, uninsured, and Medicare beneficiaries shows a 44% increase in colonoscopies among Hispanic Medicare beneficiaries post-ACA.30 After implementing policies that increase federal matching for preventive services offered to beneficiaries without cost sharing, Hispanic Medicaid beneficiaries were found to be 1.2 times more likely than white Medicaid beneficiaries to seek colonoscopies.31

Breast cancer screening:Delayed breast cancer screening is one of several reasons why Black women present with later-stage breast cancers compared to white women.32,33 The elimination of the ACA’s cost sharing component has been associated with 23% and 17% greater odds of privately insured Hispanic and Black women receiving mammograms, respectively.29 In addition, eliminating cost sharing has been associated with an increase of 8.4 percentage points in biennial mammograms among Black women enrolled in Medicare Advantage plans; no such increase was found among Hispanic women.34 Research has shown higher mammogram rates among Black, Hispanic, Asian, and Pacific Islander women enrolled in Medicare Advantage plans than those enrolled in Traditional Medicare35 (which generally has higher cost-sharing than Medicare Advantage plans).36,37 However, other research has found no association between cost sharing elimination and mammograms for Medicare beneficiaries.38

Cervical cancer screening:Cervical cancer screening was found to have increased by 92% among Hispanic women enrolled in Medicare post-ACA;30 however, other research findings did not show an increase among racial and ethnic minority Medicare beneficiaries.39 In addition, it has been shown that the probability for cervical cancer screening among privately insured racial and ethnic minorities did not increase post-ACA.29 Mixed findings on cervical cancer screening may be due to changes in the United States Preventive Services Task Force screening guidelines that occurred around the same time as ACA implementation, with 2012 updates recommending cervical cancer screening every three years instead of every year.39

Cholesterol screening:Privately insured racial and ethnic minorities have not been shown to have increased probability of receiving cholesterol screenings after the ACA reduced preventive care cost sharing requirements.29

Figure 2Percent of adults, by race, who

reported delaying or forgoing medical care due to costs in 2019

Amin K, et al. Peterson-Kaiser Family Foundation, January 202126

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Annual physicals:When evaluating pre- and post-ACA annual physical rates among publicly and privately insured adolescents, zero cost sharing has been associated with a 10% increase in annual physicals among Black and Hispanic adolescents compared to a 6% increase among white adolescents. In addition, a 10% increase in annual physicals has been found among income groups under 100% of the FPL compared to an 8% increase among income groups above 200% of the FPL.40

Contraception use:Several studies have found an association between the ACA’s elimination of cost sharing and contraception use among beneficiaries overall, but limited research has evaluated its effect on racial and ethnic minorities.41-44 When evaluating changes in birth rates and contraception prescription fill patterns among commercially insured women pre- and post-ACA, there is a significant decrease in annual rates of forgone contraception prescriptions as well as a 22% decrease in the probability of unintended births among the lowest income groups post-ACA (Fig. 3).45 While these findings do not directly assess racial and ethnic minorities, women in the study’s lowest income groups were more racially diverse, and considerable evidence indicates race and income are linked.46,47

Figure 3Estimated probability of a birth

among women aged 15–45 years, between 2008 and 2018

Dalton VK, et al. JAMA Netw Open 202045

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Cancer careCost sharing may influence racial and ethnic minorities to delay or forgo cancer care at a higher rate than whites, particularly among those enrolled in HDHPs

Research has revealed that low-income women in HDHPs waited 1.6 months longer for diagnostic breast imaging, 2.7 months longer for a biopsy, 6.6 months longer for a diagnosis, and 8.7 months longer for chemotherapy compared to low-income women with low-deductible plans.48 While this research did not directly investigate how HDHPs impact racial and ethnic minorities, there is evidence to show that race and income are linked46,47 and that breast cancer mortality is 41% higher among Black women than white women.32

Medication adherenceCost sharing may reduce medication adherence among racial and ethnic minorities

Figure 4Cumulative incidence of first major vascular event or revascularization

among nonwhite patients, by prescription coverage cohorts

Choudhry NK, et al. Health Aff (Millwood) 201451

Cumulative incidence of first major vascular event or revascularization

among white patients, by prescription coverage cohorts

Figure 5

Choudhry NK, et al. Health Aff (Millwood) 201451

Cardiovascular medication:For medications that reduce cholesterol and inflammation (e.g., statins), research has shown a three-fold increase in adherence among privately insured Black beneficiaries compared to white beneficiaries after copayments were eliminated.49 HDHPs have been associated with lower cardiovascular medication adherence among commercially insured beneficiaries overall, but this effect does not vary based on race or ethnicity.50 However, evaluating cardiovascular medication adherence among commercially insured beneficiaries has shown that eliminating cost sharing reduced rates of major vascular events by 35% and reduced out-of-pocket costs by 70% for racial and ethnic minorities, while it had no clinical or financial effect on white beneficiaries (Fig. 4 and 5).51

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Hormonal breast cancer treatment: Research evaluating hormonal breast cancer treatment among Medicare Part D beneficiaries found cost sharing to be associated with significantly lower odds of medication adherence among Black beneficiaries compared to white beneficiaries.52

Diabetes medication:An association between cost sharing and lower adherence to diabetes medication has been found among privately insured Black and Hispanic beneficiaries.53

COVID-19 effects on

cost sharing

Cost sharing and COVID-19

in Washington state

Under an Insurance

Commissioner emergency

order extended to August

8, 2021, all health insurance

plans must cover COVID-19

testing and treatment with

zero cost sharing. In addition,

vaccines must remain available

with zero cost sharing under

the federal Coronavirus Aid,

Relief, and Economic Security

(CARES) Act.54

COVID-19 effect on racial

and ethnic minorities

Though cost sharing has been

eliminated for most COVID-

19-related services, racial and

ethnic minorities continue

to experience lower rates of

testing and vaccination55,56

as well as higher rates of

morbidity and mortality9, 57

due to the virus compared to

whites.

Cost Containment Moving ForwardIn the U.S., high healthcare spending continues to plague individuals, families, businesses, and government. As federal and Washington state policy makers continue efforts to control healthcare costs and expendi-tures, they should consider the unintended harm that cost sharing may cause among racial and ethnic minorities. Given that cost sharing has not been shown to be a widely effective method for controlling spend-ing, policy makers should consider other strategies.

Expand reduced or eliminated cost sharing across health insurance plans and maintain cost sharing waivers for COVID-19 care in perpetuityReduced or eliminated cost sharing across health insurance plans should be expanded, and COVID-19 testing, treatment, and vaccines should be provided with reduced or zero sharing in perpetuity, particularly in light of new and emerging COVID-19 variants.58 While it is known that social determinants of health, such as low socioeconomic status, living in a rural area, and lack of transportation, reduce access to care among racial and ethnic minorities, work to address these determinants may take time (Fig.6).59 Cost sharing reductions are immediate actions that can be taken by policy makers to improve health equity.

Evaluate the effect that Washington state’s Cascade Care plans have had on healthcare disparitiesOpened in January 2021, Washington state’s Cascade Care plans feature lower deductibles than other Health Benefit Exchange plans, more services provided before the deductible (including preventive care, primary care, urgent care, behavioral health services, and generic drugs), more transparent cost sharing policies, and improved marketing and outreach strategies to improve health insurance literacy.60 These features should be evaluated for their ability to reduce disparities in healthcare access and use, and improvements should be made where necessary.

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Expand value-based careValue-based care—where higher levels of cost sharing are required for lower value services—has been shown to reduce healthcare expenditures without causing undue harm.61,62 Compared to undifferentiated cost sharing, value-based care harnesses variation in service value to reduce spending and improve healthcare quality.

Increase research on the effect of cost sharing among racial and ethnic minoritiesMany studies have examined the effect of cost sharing on beneficiaries overall, but few have focused on racial and ethnic minorities specifically. Given the healthcare disparities highlighted and exacerbated by the COVID-19 pandemic, this research is needed to inform more equitable cost sharing policies, such as income-based cost sharing requirements.63

Reduce the price of medical goods and services either through regulatory or market-based strategiesNumerous studies have concluded that the main reason for high healthcare spending in the U.S.—and the main reason it spends so much more than other industrialized countries—is the price of medical goods and services, rather than their use.64,65 Policy makers may consider additional antitrust regulations similar to Washington state House Bill 1607, enacted in January 2020, which aims to ensure healthcare market competition that benefits consumers.66 Policy makers may also consider limiting growth on prices paid by commercial insurers67 as well as efforts to increase price transparency led by bodies such as Washington State’s Health Care Cost Transparency Board.68

Address social determinants of health Finally, as cost sharing structures are amended and additional cost containment strategies are implemented, policy makers should continue to address non-financial barriers to healthcare access, such as social determinants of health, which limit the success of policies aimed at reducing healthcare disparities.69,70 The need to consider non-financial barriers to healthcare access is supported by evidence outside of the U.S. where disparities in care persist despite universal health insurance coverage and zero cost sharing.71

Soci

al D

eter

min

ants

of H

ealth Economic Stability

Community & Social Context

Education

Food

Neighborhood & Physical Environment

Healthcare

Barriers to Access Healthcare

Supply sideGeographic maldistributionFinancial maldistributionNarrow provider networksBias (explicit, implicit)Restrictive hours

Demand sideUnaffordabilityLack of insuranceInadequate knowledgeReluctance to seek careInadequate transportation options

Figure 6Social determinants of health

and healthcare

Booshehri LG, Dugan J. University of Washington Center for Health Innovation and Policy Science,

August 202159

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9

References

ConclusionAs work continues to address the more systemic factors, such as social determinants of health, that limit access to healthcare for many racial and ethnic minorities, state and federal policy makers have an opportunity to enact immediate change by expanding cost sharing reductions and implementing more effective and equitable cost containment methods. These methods, including addressing the price of medical goods and services, evaluating Washington state Cascade Care plans, and expanding value-based healthcare delivery models, have the potential to reduce healthcare expenditures while removing the burden of cost sharing as a blunt cost containment strategy. Doing so will recenter patient health as the primary goal of healthcare.

1. Centers for Medicare and Medicaid Services. National health expenditure fact sheet. Centers for Medicare and Medicaid Services website. December 16, 2020. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NHE-Fact-Sheet. Accessed July 15th, 2021.

2. Peter G. Peterson Foundation. Why are Americans paying more for healthcare? Peter G. Peterson Foundation website. April 20, 2020. https://www.pgpf.org/blog/2020/04/why-are-americans-paying-more-for-healthcare. Accessed July 2, 2021.

3. Remler DK, Greene J. Cost-sharing: a blunt instrument. Annu Rev Public Health. 2009;30:293-311. doi:10.1146/annurev.publhealth.29.020907.090804

4. Baicker K, Goldman D. Patient cost-sharing and healthcare spending growth. J Econ Perspect. 2011;25(2):47-68. doi:10.1257/jep.25.2.47

5. Rice T. The impact of cost containment efforts on racial and ethnic disparities in health care: a conceptualization. In: Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. National Academies Press (US), 2003: 699-721.

6. Manning WG, Newhouse JP, Duan N, Keeler EB, Leibowitz A, Marquis MS. Health insurance and the demand for medical care: evidence from a randomized experiment. Am Econ Rev. 1987;77(3):251-277. https://pubmed.ncbi.nlm.nih.gov/10284091/. Accessed July 22, 2021.

7. Bibbins-Domingo K. This Time Must Be Different: Disparities During the COVID-19 Pandemic. Ann Intern Med. 2020;173(3):233-234. doi:10.7326/M20-2247

8. Centers for Disease Control and Prevention. Impact of racism on our nation’s health. Centers for Disease Control and Prevention website. April 8th, 2021. https://www.cdc.gov/healthequity/racism-disparities/impact-of-racism.html. Accessed July 22, 2021.

9. Bailey ZD, Krieger N, Agénor M, Graves J, Linos N, Bassett MT. Structural racism and health inequities in the USA: evidence and interventions. Lancet. 2017;389(10077):1453-1463. doi:10.1016/S0140-6736(17)30569-X

10. Seattle Foundation. Overview of COVID-19 impacts on BIPOC communities in King County. Seattle Foundation website. July 2020. https://www.seattlefoundation.org/-/media/SeaFdn/Files/COVID-19/SeaFdn-COVID-19-Impact-Overview_November-2020.pdf?la=en&hash=45E3DA6CED774276BA3A2E0D09B12690C23C4384. Accessed July 20, 2021.

11. Kaiser Family Foundation. Health insurance coverage of the total population. Kaiser Family Foundation website. https://www.kff.org/other/state-indicator/total-population/?currentTimeframe=0&selectedDistributions=employer--non-group--medicare--military&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D#notes. Accessed July 20, 2021.

12. Kaiser Family Foundation. Premiums for employer-sponsored family health coverage rise 5% to average $19,616; single premiums rise 3% to $6,896. October 3, 2018. https://www.kff.org/health-costs/press-release/employer-sponsored-family-coverage-premiums-rise-5-percent-in-2018/. Accessed July 24, 2021.

13. Collins SR, Radley, DC. The cost of employer insurance is a growing burden for middle-income families. The Commonwealth Fund website. December 2018. https://www.commonwealthfund.org/publications/issue-briefs/2018/dec/cost-employer-insurance-growing-burden-middle-income-families. Accessed July 20, 2021.

14. Miller GE, Vistnes JP, Rohde F, Keenan PS. High-Deductible Health Plan Enrollment Increased From 2006 To 2016, Employer-Funded Accounts Grew In Largest Firms. Health Aff (Millwood). 2018;37(8):1231-1237. doi:10.1377/hlthaff.2018.0188

This is the second brief in a three-part series on health care access barriers in Washington state. CHIPS researchers are open to investigating policy questions across the public health and health policy domains.

Please contact us at uwchips@uw.edu with any inquiries.

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15. Koma W, Cubanski J, Neuman, T. A snapshot of sources of coverage among Medicare beneficiaries in 2018. Kaiser Family Foundation website. March 23, 2021. https://www.kff.org/medicare/issue-brief/a-snapshot-of-sources-of-coverage-among-medicare-beneficiaries-in-2018/. Accessed July 22, 2021.

16. Kaiser Family Foundation. Premium and cost-sharing requirements for selected services for Medicaid adults. January 2, 2020. https://www.kff.org/health-reform/state-indicator/premium-and-cost-sharing-requirements-for-selected-services-for-medicaid-expansion-adults/?currentTimeframe=0&selectedRows=%7B%22states%22:%7B%22-washington%22:%7B%7D%7D%7D&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. Accessed July 20, 2021.

17. Department of Health and Human Services. Patient protection and affordable care act; HHS notice of benefit and payment parameters for 2021; notice requirement for non-federal governmental plans. Department of Health and Human Services website. May 14, 2020. https://www.govinfo.gov/content/pkg/FR-2020-05-14/pdf/2020-10045.pdf. Accessed July 20, 2021.

18. Centers for Medicare and Medicaid. Health coverage for American Indians & Alaska Natives. Centers for Medicare and Medicaid website. https://www.healthcare.gov/american-indians-alaska-natives/. Accessed July 20, 2021.

19. Altman, J. Update from the Health Benefit Exchange: state subsidy implementation plan. Washington Health Benefit Exchange website. December 2, 2020. https://www.wahbexchange.org/content/dam/wahbe/2020/12/HBE_SHC_Subsidy-Update_FINAL_external.pdf. Accessed July 20, 2021.

20. Quincy L. Making health insurance cost-sharing clear to consumers: challenges in implementing health reform’s insurance disclosure requirement. The Commonwealth Fund website. February 2011. https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_issue_brief_2011_feb_1480_quincy_making_hlt_ins_costsharing_clear_consumers_ib.pdf. Accessed July 20, 2021.

21. Paez KA, Mallery CJ. A little knowledge is a risky thing: wide gap in what people think they know about health insurance and what they actually know. American Institutes for Research website. October 2014. https://www.air.org/sites/default/files/Health%20Insurance%20Literacy%20brief_Oct%202014_amended.pdf. Accessed July 20, 2021.

22. Edward J, Wiggins A, Young MH, Rayens MK. Significant Disparities Exist in Consumer Health Insurance Literacy: Implications for Health Care Reform. Health Lit Res Pract. 2019;3(4):e250-e258. doi:10.3928/24748307-20190923-01

23. Villagra VG, Bhuva B, Coman E, Smith DO, Fifield J. Health insurance literacy: disparities by race, ethnicity, and language preference. Am J Manag Care. 2019;25(3):e71-e75. https://pubmed.ncbi.nlm.nih.gov/30875174/. Accessed July 20, 2021.

24. Piette JD, Heisler M. The relationship between older adults’ knowledge of their drug coverage and medication cost problems. J Am Geriatr Soc. 2006;54(1):91-96. doi:10.1111/j.1532-5415.2005.00527.x

25. Kue J, Zukoski A, Keon KL, Thorburn S. Breast and cervical cancer screening: exploring perceptions and barriers with Hmong women and men in Oregon. Ethn Health. 2014;19(3):311-327. doi:10.1080/13557858.2013.776013

26. Amin K, Claxton G, Ramirez G. How does cost affect access to care? Peterson-Kaiser Family Foundation website. January 5, 2021. Accessed July 20, 2021. https://www.healthsystemtracker.org/chart-collection/cost-affect-access-care/.

27. Artiga S, Ubri P, Zur J. The effects of premiums and cost sharing on low-income populations: updated review of research findings. Kaiser Family Foundation website. June 1, 2017. Accessed July 20, 2021. https://www.kff.org/medicaid/issue-brief/the-effects-of-premiums-and-cost-sharing-on-low-income-populations-updated-review-of-research-findings/.

28. National Health Data Center. National aggregated health center data. 2019. Accessed July 20, 2021. https://data.hrsa.gov/tools/data-reporting/program-data/national

29. Agirdas C, Holding JG. Effects of the ACA on Preventive Care Disparities. Appl Health Econ Health Policy. 2018;16(6):859-869. doi:10.1007/s40258-018-0423-5

30. Bhandari NR, Li C. Impact of The Affordable Care Act’s Elimination of Cost-Sharing on the Guideline-Concordant Utilization of Cancer Preventive Screenings in the United States Using Medical Expenditure Panel Survey. Healthcare (Basel). 2019;7(1):36. doi:10.3390/healthcare7010036

31. O’Leary MC, Lich KH, Gu Y, et al. Colorectal cancer screening in newly insured Medicaid members: a review of concurrent federal and state policies. BMC Health Serv Res. 2019;19(1):298. doi:10.1186/s12913-019-4113-2

32. Richardson LC, Henley SJ, Miller JW, Massetti G, Thomas CC. Patterns and trends in age-specific black-white differences in breast cancer incidence and mortality – United States, 1999–2014. Centers for Disease Control and Prevention website. October 14, 2016. Accessed July 20, 2021. https://www.cdc.gov/mmwr/volumes/65/wr/mm6540a1.htm

33. Smith-Bindman R, Miglioretti DL, Lurie N, et al. Does utilization of screening mammography explain racial and ethnic differences in breast cancer?. Ann Intern Med. 2006;144(8):541-553. doi:10.7326/0003-4819-144-8-200604180-00004

34. Trivedi AN, Leyva B, Lee Y, Panagiotou OA, Dahabreh IJ. Elimination of Cost Sharing for Screening Mammography in Medicare Advantage Plans. N Engl J Med. 2018;378(3):262-269. doi:10.1056/NEJMsa1706808

35. Ayanian JZ, Landon BE, Zaslavsky AM, Newhouse JP. Racial and ethnic differences in use of mammography between Medicare Advantage and traditional Medicare. J Natl Cancer Inst. 2013;105(24):1891-1896. doi:10.1093/jnci/djt333

36. Medicare Payment Advisory Commission. Benefit design and cost sharing in Medicare Advantage Plans. Medicare Payment Advisory Commission website. December 2004. Accessed July 20, 2021. http://medpac.gov/docs/default-source/reports/Dec04_CostSharing.pdf

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37. Freed M, Biniek JF, Damico A, Neuman T. Medicare Advantage in 2021: premiums, cost sharing, out-of-pocket limits and supplemental benefits. Kaiser Family Foundation website. June 21, 2021. Accessed July 20, 2021. https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2021-premiums-cost-sharing-out-of-pocket-limits-and-supplemental-benefits/

38. Xu WY, Wickizer TM, Jung JK. Effectiveness of Medicare cost-sharing elimination for Cancer screening on utilization. BMC Health Serv Res. 2019;19(1):392. doi:10.1186/s12913-019-4135-9

39. Alharbi A, Khan MM, Horner R, Brandt H, Chapman C. Impact of removing cost sharing under the affordable care act (ACA) on mammography and pap test use. BMC Public Health. 2019;19(1):370. doi:10.1186/s12889-019-6665-9

40. Adams SH, Park MJ, Twietmeyer L, Brindis CD, Irwin CE Jr. Association Between Adolescent Preventive Care and the Role of the Affordable Care Act [published correction appears in JAMA Pediatr. 2018;172(1):98]. JAMA Pediatr. 2018;172(1):43-48. doi:10.1001/jamapediatrics.2017.3140

41. Carlin CS, Fertig AR, Dowd BE. Affordable Care Act’s Mandate Eliminating Contraceptive Cost Sharing Influenced Choices Of Women With Employer Coverage. Health Aff (Millwood). 2016;35(9):1608-1615. doi:10.1377/hlthaff.2015.1457

42. Pace LE, Dusetzina SB, Keating NL. Early Impact Of The Affordable Care Act On Oral Contraceptive Cost Sharing, Discontinuation, And Nonadherence. Health Aff (Millwood). 2016;35(9):1616-1624. doi:10.1377/hlthaff.2015.1624

43. Snyder AH, Weisman CS, Liu G, Leslie D, Chuang CH. The Impact of the Affordable Care Act on Contraceptive Use and Costs among Privately Insured Women. Womens Health Issues. 2018;28(3):219-223. doi:10.1016/j.whi.2018.01.005

44. Becker NV, Keating NL, Pace LE. ACA Mandate Led To Substantial Increase In Contraceptive Use Among Women Enrolled In High-Deductible Health Plans. Health Aff (Millwood). 2021;40(4):579-586. doi:10.1377/hlthaff.2020.01710

45. Dalton VK, Moniz MH, Bailey MJ, et al. Trends in Birth Rates After Elimination of Cost Sharing for Contraception by the Patient Protection and Affordable Care Act. JAMA Netw Open. 2020;3(11):e2024398. doi:10.1001/jamanetworkopen.2020.24398

46. Bhutta N, Chang AC, Dettling LG, Hsu, JW. and Joanne W. Hsu. Disparities in wealth by race and ethnicity in the 2019 Survey of Consumer Finances. Board of Governors of the Federal Reserve System. September 29, 2020. Accessed July 20, 2021. https://www.federalreserve.gov/econres/notes/feds-notes/disparities-in-wealth-by-race-and-ethnicity-in-the-2019-survey-of-consumer-finances-20200928.htm

47. Manduca R. Income inequality and the persistence of racial economic disparities. Sociological Science. 2018. doi:10.15195/v5.a8

48. Wharam JF, Zhang F, Wallace J, et al. Vulnerable And Less Vulnerable Women In High-Deductible Health Plans Experienced Delayed Breast Cancer Care. Health Aff (Millwood). 2019;38(3):408-415. doi:10.1377/hlthaff.2018.05026

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