Medicaid expansions and differences in guideline-adherent cervical cancer screening between American Indian and White women

Background: Although preventable through screening, cervical cancer incidence and mortality are higher among American Indian and Alaska Native women (AIAN) than White women. The Patient Protection and Affordable Care Act's (ACA) Medicaid expansions may uniquely impact access and use of cervical cancer screening among AIAN women and ultimately alleviate this disparity.Methods: Using Medicaid eligible AIAN (N = 4681) and White (N = 57,661) women aged 18- 64 years from the 2010- 2020 Behavioral Risk Factor Surveillance System, we implemented difference- in-differences regression to estimate the association between the Medicaid expansions and guideline-adherent cervical cancer screening and health care coverage.Results: The Medicaid expansions were not associated with guideline-adherent cervical cancer screening (AIAN: -1 percentage point [ppt] [95% confidence in-terval, CI: -4, 2 ppts]; White: 3 ppts [95% CI: -0, 6 ppts]), but were associated with a 2 ppt increase (95% CI: 0, 4 ppt) in having had a pap test in the last 5 years among White women. The Medicaid expansions were also associated with in-creases in having a health plan (AIAN: 5 ppts [95% CI: 1, 9]; White: 11 ppts [95% CI: 7, 15]) and decreases in avoiding medical care due to costs (AIAN: -8 ppts [95% CI: -13, -2]; White: -6 ppts [95% CI: -9, -4]).Conclusions: While we observed improvements in health care coverage, we did not observe changes to guideline-adherent cervical cancer screening following the ACA's Medicaid expansions. Given the disproportionate burden of cervical cancer among AIAN women, identifying ways to improve cervical cancer screen-ing uptake and delivery should be prioritized to reduce preventable deaths.