A difference-in-differences analysis of Medicaid expansion and state paid sick leave laws on colorectal cancer screening

Background: Colorectal cancer (CRC) screening disparities persist among populations with limited health care access. Although Medicaid expansion and paid sick leave could address these barriers, there is limited data on the combined impact of these policies and CRC screening. Methods: The authors conducted a difference-in-differences analysis using 2012–2018 Behavioral Risk Factor Surveillance System data. The study population included adults 50–75 years of age meeting preventive cancer screening guidelines during the study period. States were categorized into three groups: those with Medicaid expansion and paid sick leave (ME + SL), Medicaid expansion without paid sick leave (MEnoSL), and neither policy (NoME/NoSL). The pre-policy period was 2012–2014 and the post-policy period was 2015–2018. The outcome was the percent up-to-date with CRC screening. Survey-weighted logistic regression models accounted for individual- and state-level covariates and state-clustered standard errors. Results: Post-policy implementation, CRC up-to-date screening was 2.9 percentage points greater in ME + SL states compared to MEnoSL states (p <.001) and 4.2 percentage points greater compared to NoME/NoSL states (p =.018). These changes correspond to an estimated 352,343 and 1,087,140 fewer missed screenings between ME + SL and MEnoSL and NoME/NoSL states, respectively. The increased percent of up-to-date CRC screenings was associated with a reduction in colorectal cancer deaths: 8456 from ME + SL versus MEnoSL and 26,091 from ME + SL versus NoME/NoSL. Conclusions: Medicaid expansion combined with paid sick leave was associated with a greater likelihood of being up-to-date with CRC screening compared to Medicaid expansion alone or neither policy.