Date of Award

Spring 4-2019

Degree Name

Doctor of Philosophy (PhD)



Second Advisor


Third Advisor



Preventive cancer screenings are essential to early detect cancer and subsequently save lives. However, out-of-pocket expenditures for cancer screening services deter individuals from obtaining them. In an effort to improve the utilization of cancer screening, the Affordable Care Act (ACA) implemented a cost-sharing elimination provision that removes all forms of cost sharing including copayments, co-insurance and deductibles from certain preventive care services that are recommended by widely known scientific figures such as the United States Preventive Services Task Force (USPSTF). This study evaluated the impact of the ACA cost-sharing elimination provision for preventive care services from 2008 through 2016 using a differences in differences (DID) approach. The approach compared utilization changes overtime between the insured (treatment group) and the uninsured (control group). This study investigated the impact of the ACA cost sharing elimination provision on the utilization of three cancer prevention screenings, particularly, breast, cervical, and colorectal cancer screenings, among individuals who were privately insured and/or Medicare-insured, before and after the cost-sharing elimination provision enactment. This provision became effective for private health insurance plans, in 2010, and for Medicare, in 2011. A focus of this dissertation was to examine the influence of socio-economic and socio viii demographic factors on utilization changes. These factors were determined with the guidance of the Andersen Healthcare Utilization model which states that the usage of health services is determined by the three dynamics: predisposing, enabling, and need factors. This study utilized data from the national Medical Expenditure Panel Survey (MEPS). The MEPS is a nationally representative survey of non-institutionalized United States (US) individuals and families. The results of this dissertation expand the current knowledge of the impact of the ACA cost-sharing elimination provision on increasing utilization of three cancer screenings and provides policy makers and health professionals with much needed information for decision making. The results of this study demonstrate that the ACA cost-sharing elimination provision did not have an impact on the utilization of the examined cancer screening services including mammography, Pap smear, FOBT, colonoscopy and sigmoidoscopy. However, there were some predisposing, enabling, and need factors that showed a significant effect on utilization rates, suggesting that future research is necessary to understand and evaluate the impact of cost-sharing on access to cancer preventive care services