Can Legal Knowledge Save Lives? A Randomized Experiment in Preventive Health Screenings

Abstract

While the U.S. healthcare system typically imposes significant out-of-pocket costs on those with insurance, the Affordable Care Act (ACA) requires full coverage of certain preventive health services. Still, one in four eligible Americans remains unscreened for breast, colorectal, and cervical cancer. We hypothesize that a lack of awareness about the ACA’s requirement contributes to this gap. Additionally, we investigate whether prior experiences with medical debt deter individuals from seeking even free care, a potential 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). We determined whether each one qualified for a free cancer screen based on age and sex, and found that n=1,406 had not received at least one recommended cancer screening. Those 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 was not observed directly.

As hypothesized, FCD increased screening-related behavior by 5 percentage points (p = .031), with effects varying by cancer type.  Consistently, 45% of respondents indicated that “costs or coverage” was a common reason for having not gotten screening, and large majorities agreed that “going to the doctor or hospital can be dangerous financially,” “the American healthcare system is full of tricks and traps,” and “in America, healthcare is never really free” (80%, 65%, and 91% agreeing respectively).  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.

Keywords: randomized experiment, preventive health, cancer, Affordable Care Act, cost exposure, health care cost, legal knowledge