Insurance and cancer
Report Links Health Insurance Status With Cancer Care
American Cancer Society
December 20, 2007
Uninsured Americans are less likely to get screened for cancer, more likely to be diagnosed with an advanced stage of the disease, and less likely to survive that diagnosis than their privately insured counterparts, according to a new American Cancer Society report examining the impact of health insurance status on cancer treatment and survival.
American Cancer Society researchers analyzed 598,635 cases using the most recent data from the National Cancer Data Base (NCDB), a hospital-based registry held by ACS and the Commission on Cancer of the American College of Surgeons. The NCDB tracks approximately 70% of the cancer cases in the United States and collects data from about 1,500 hospitals. The patients included had either private insurance, Medicaid, or no insurance. The researchers also examined data from the 2005 and 2006 National Health Interview Survey (NHIS), a nationwide in-person survey of approximately 40,000 U.S. households conducted by the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention (CDC).
For all cancers combined, the ACS researchers found that uninsured patients were 1.6 times as likely to die within 5 years compared to individuals with private insurance.
People with lower incomes were less likely to have insurance, the report found. And those without insurance were less likely to use certain health services. About 54% of uninsured patients aged 18 to 64 did not have a usual source of health care. About 26% delayed care due to cost, while nearly 23% did not get care because of cost. An estimated 23% did not get prescription drugs because of the expense.
Individuals with health insurance were about twice as likely as those without to have had a recent mammogram or colorectal cancer screening. People with insurance were also more likely to be diagnosed with early stage disease and less likely to be diagnosed with advanced stage disease than the uninsured.
The researchers saw a survival difference in breast and colorectal cancer, too. About 89% of privately insured white women with breast cancer survived at least 5 years, compared to 76% of white women with Medicaid or no insurance. Among African-American women, 81% of breast cancer patients with private insurance survived 5 years, compared to 65% of those on Medicaid and 63% of those without insurance. A similar pattern emerged in colorectal cancer. Among white patients with private insurance, 66% survived 5 years, compared to 50% of those with no insurance and 46% of those on Medicaid. Among African Americans, 60% with private insurance survived 5 years compared to 41% of the uninsured and Medicaid patients.
The risk of being uninsured or underinsured varies.
Almost anyone can be underinsured in the event of a major illness. The underinsured, commonly defined as people who spend more than 10% of their after-tax household income on out-of-pocket expenses in the event of a serious illness, often don’t realize the gravity of their situation until faced with high premiums and deductibles, limits on terms for covered services, and caps on monthly, lifetime, or disease-specific coverage.
According to a 2003 study sponsored by the Agency for Health Care Research and Quality, the prevalence of being underinsured increased from 6.7% to 8.5% among nonelderly adults between 1996 and 2003. These numbers shot up when the costs of health insurance premiums were factored in. Among people with cancer, 29% had out-of-pocket expenses that exceeded 10% of their family’s income and about 11% exceeded it by 20%.
“Association of Insurance with Cancer Care Utilization and Outcomes” January/February 2008 issue of CA: A Cancer Journal for Clinicians, published by the American Cancer Society:
http://caonline.amcancersoc.org/
Comment:
By Don McCanne, MD
There are many factors that influence access and outcomes for cancer patients. This comprehensive study confirms that insurance status is one of the most important factors. The uninsured are screened less frequently; they are diagnosed at a later stage, and they have a lower survival rate.
Because of socioeconomic and other factors, insuring everyone will not eliminate these disparities. But financial barriers perpetuate and intensify the disparities. The crucial first step to improve health care for cancer patients (and for all other patients) is to remove financial barriers by including everyone in a comprehensive national health insurance program.
This study raises another important issue. Not only is insurance coverage crucial, the nature of that coverage counts as well.
Somewhat shocking is that the survival of Medicaid patients in this study was no better than that of the uninsured. Part of this is likely due to the reality that Medicaid is a chronically underfunded medical welfare program. Many health care providers refuse to accept Medicaid patients. Using Medicaid to reduce financial barriers is of little help when the health care delivery system has shut its doors to those enrolled in the program.
Another factor that may result in a lower survival rate for Medicaid patients is that many were previously uninsured or lost the coverage they had, so they use Medicaid as rescue coverage, inevitably entering the system at a later stage of their disease. But this only further confirms that it is not an adequate substitute for continuous comprehensive coverage that provides sufficient funding for the health care delivery system.
Another important reason that universal insurance coverage alone is not enough is that underinsurance has become a source of financial hardship, precisely for those with significant health care needs such as cancer patients. Not only does underinsurance create a hardship, it also is a barrier to care when the patient cannot afford his/her expensive chemotherapy because it isn’t covered by the plan.
Medical welfare programs and inadequate coverage can never patch the vast holes in our health care system. Again, there is much to be done, but all other efforts will be relatively feeble until we remove financial barriers to care for everyone by enacting a single payer national health insurance program. That’s the easy step. Then we need to go to work.