The effect of being uninsured on cancer screening practices in Puerto Rico

Context Access to preventative health screening, particularly cancer screening, is a fundamental aspect of public health and is closely linked to reduced burden of disease. One of the largest barriers to preventative cancer screening is inadequate insurance coverage. Although disparities in healthcare access have been well-documented between insured and uninsured populations in the United States, the impact of lack of insurance on screening practices in Puerto Rico has not been well described.

Objective To evaluate cancer screening practices in Puerto Rico and study the effect of healthcare insurance status on cancer screening.

Study Design and Analysis This is a cross-sectional study. Descriptive statistics were done. Unadjusted bivariate analysis was used to assess the relationship between insurance status and cancer screening using Chi-square for categorical variables, and two sample Wilcoxon-Mann-Whitney rank-sum test for continuous variables.

Setting or Dataset We used data from the Puerto Rico Behavioral Risk Factor Surveillance System (PR-BRFSS) for the years 2018, 2020 and 2022.

Population Studied Adults aged ≥ 18 years who completed any of the PR-BRFSS surveys for the three years of interest.

Outcomes Measures Using age recommendations for screening, we compared the proportion of individuals who ever had a mammography, cervical cancer screening, colonoscopy, and alternative colon cancer screening for insured and uninsured individuals.

Results The study population for years 2018 (n=4,843 persons), 2020 (4,944 persons) and 2022 (5,509 persons) was 15,296 persons of which 5.34% (n=814) were uninsured. Most participants were women (60.89%), had completed at least high school (62.05%) and had a median income lower than $25,000 per year (54.02%). The proportion of participants who reported that they ever had a screening test was statistically significantly lower (p<0.001) for uninsured compared to insured individuals for mammography (61.54% vs 76.11%), cervical cancer screening (33.21% vs 54.69%), colonoscopy (10.46% vs 37.05%) and alternative colon cancer screening (8.64% vs 28.39%) respectively.

Conclusion Cancer screening rates were lower among individuals without healthcare insurance, which highlights the importance of understanding and addressing barriers to obtaining healthcare coverage and the need for targeted evidence-based interventions to support access to screening services in this population.