Document Type
Working Paper
Publication Date
5-2025
Language
en-US
Abstract
While the U.S. healthcare system typically imposes significant out-of-pocket costs, the Affordable Care Act (ACA) requires full insurance coverage for certain preventive health services (PHS), including cancer screenings, without cost-sharing. Despite this policy, one in four eligible Americans remains unscreened for breast, colorectal, and cervical cancer, which increases their risk of premature death. We hypothesize that a lack of awareness about the ACA’s free care requirement contributes to this gap and that explicitly informing patients could increase screening uptake. Additionally, we investigate whether prior experiences with medical debt deter individuals from seeking even cost-free care, reflecting a spillover effect of broader healthcare cost burdens.
We conducted an online survey experiment with 3,354 insured U.S. adults aged 30–74 with moderate household incomes ($30k–$99k), and we determined whether each one was qualified for a free cancer screen based on age and sex. Among them, 1,406 had not received at least one recommended cancer screening. Participants were randomly assigned to one of four conditions in a 2×2 factorial design. In the “free care disclosure” (FCD) treatment, half were informed that ACA-required screenings are fully covered without copays or deductibles. In the “medical debt salience” (MDS) treatment, half were asked about their medical debt history before assessing screening intentions. In addition to measures of intention, the primary outcome was behavioral—whether participants requested a link to take a step toward screening, a proxy for screening behavior, which we were not able to observe directly. We also tracked self-expressed intentions to get screened.
As hypothesized, FCD increased screening-related action by 5 percentage points (p = .031). Effects varied by cancer type, with larger effects for colon and cervical cancers, but with no impact—and a potential negative (non-significant) effect—for breast cancer screening. Survey responses were consistent with this experimental finding for FCD overall, with “costs or coverage” being the third most common reason respondents cited for having not gotten screening (at 45% of respondents), and with large majorities agreeing that “going to the doctor or hospital can be dangerous financially” (80% agreeing), “the American healthcare system is full of tricks and traps” (65% agreeing) and “in America, healthcare is never really free” (91% agreeing). MDS had no direct effect on behavior, but contrary to hypothesis, individuals with medical debt were more likely to seek screening than those without (p = .011).
These findings suggest that lack of awareness about the law providing free preventive care is a significant barrier to screening. Proactive communication by clinicians or public health officials could save lives. The larger paradigm of cost-exposure has a negative spillover, and ignorance of this benefit may be a preventable cause of cancer-related mortality.
Recommended Citation
Christopher Robertson & Wendy Netter Epstein,
Can Legal Knowledge Save Lives? A Randomized Experiment in Preventive Health Screenings
(2025).
Available at:
https://scholarship.law.bu.edu/faculty_scholarship/4093
