Breast Cancer Screening Among Women with Medicaid, 2006–2008: a Multilevel Analysis

  • Lee Rivers Mobley
  • Sujha Subramanian
  • Florence K. Tangka
  • Sonja Hoover
  • Jiantong Wang
  • Ingrid J. Hall
  • Simple D. Singh



Nationally, about one third of women with breast cancer (BC) are diagnosed at late stage, which might be reduced with greater utilization of BC screening. The purpose of this paper is to examine the predictors of BC mammography use among women with Medicaid, and differences among Medicaid beneficiaries in their propensity to use mammography.


The sample included 2,450,527 women drawn from both fee-for-service and managed care Medicaid claims from 25 states, during 2006–2008. The authors used multilevel modeling of predictors at person, county, and state levels of influence and examined traditional factors affecting access and the expanded scope of practice allowed for the nurse practitioner (NP) in some states to provide primary care independent of physician oversight.


Black [OR = 0.87; 95 % CI (0.87–0.88)] and American Indian women [OR = 0.74; 95 % CI (0.71–0.76)] had lower odds ratio of mammography use than white women, while Hispanic [OR = 1.06; 95 % CI (1.05–1.07)] had higher odds ratio of mammography use than white women. Living in counties with higher Hispanic residential segregation [OR = 1.16; 95 % CI (1.10–1.23)] was associated with a higher odds ratio of mammography use compared to areas with low Hispanic residential segregation, whereas living among more segregated black [OR = 0.78; 95 % CI (0.75–0.81)] or Asian [OR = 0.19; 95 % CI (0.17–0.21)] communities had lower odds ratio compared to areas with low segregation. Holding constant statistically the perceived shortage of MDs, which was associated with significantly lower mammography use, the NP regulatory variable [OR = 1.03; 95 % CI (1.01–1.07)] enhanced the odds ratio of mammography use among women in the six states with expanded scope of practice, compared with women residing in 19 more restrictive states.


Racial and ethnic disparities exist in the use of mammography among Medicaid-insured women. More expansive NP practice privileges in states are associated with higher utilization, and may help reduce rural disparities.


Breast cancer screening Medicaid Multilevel analysis Racial or ethnic disparities Racial or ethnic residential segregation Nurse practitioner regulation 



The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Funding support for Lee Mobley, Sujha Subramanian, Sonja Hoover, and Jiantong Wang was provided by the Centers for Disease Control and Prevention (Contract No. 200-2008-27958, Task order 35, to RTI International).

Compliance with Ethical Standards

The authors have no potential conflicts of interest to disclose. The research does not involve human participants or animals and did not require informed consent. This manuscript has not been submitted to more than one journal for simultaneous consideration. This manuscript has not been published previously (partly or in full). This study has not been split up into several parts to increase the quantity of submissions and submitted to various journals or to one journal over time. No data have been fabricated or manipulated (including images) to support our conclusions. No data, text, or theories by others are presented as if they were the author’s own. Proper acknowledgements to other works have been given. Consent to submit has been received explicitly from all co-authors, as well as from the responsible authorities—tacitly or explicitly—at the institute/organization where the work has been carried out. Authors whose names appear on this manuscript have contributed sufficiently to the scientific work and therefore share collective responsibility and accountability for the results.


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Copyright information

© W. Montague Cobb-NMA Health Institute 2016

Authors and Affiliations

  • Lee Rivers Mobley
    • 1
  • Sujha Subramanian
    • 2
  • Florence K. Tangka
    • 3
  • Sonja Hoover
    • 2
  • Jiantong Wang
    • 2
  • Ingrid J. Hall
    • 3
  • Simple D. Singh
    • 3
  1. 1.School of Public Health and Andrew Young School of Policy StudiesGeorgia State UniversityAtlantaUSA
  2. 2.RTI InternationalWalthamUSA
  3. 3.Division of Cancer Prevention and ControlCenters for Disease Control and PreventionAtlantaUSA

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