Report Links Health Insurance Status With Cancer Care (American Cancer Society)

Uninsured Americans are less likely to get screened forcancer, more likely to be diagnosed with an advanced stage of thedisease, and less likely to survive that diagnosis than their privatelyinsured counterparts, according to a new American Cancer Society reportexamining the impact of health insurance status on cancer treatment andsurvival.
The article, posted online today and set to be published inthe January-February 2008 issue of CA:A Cancer Journal for Clinicians, the peer-reviewed journalof the American Cancer Society, was authored by American Cancer Societyresearchers, led by Elizabeth Ward, PhD, managing director,surveillance research.
Previousstudies have shown that uninsured and Medicaidpatients are more likely to be diagnosed with late-stage cancers, inlarge part because they can't afford preventive services and cancerscreening. This report looks at the relationship between healthinsurance status and cancer care more closely, weighing demographic andsocioeconomic factors as well as race.
"This report clearly suggests that insurance and cost-relatedbarriers to care are critical to address if we want to ensure that allAmericans are able to share in the progress we have achieved by havingaccess to high-quality cancer prevention, early detection, andtreatment services," said OtisBrawley, MD, chief medical officer ofthe American Cancer Society, when the report was released.
Many Forego Care
American Cancer Society researchers analyzed 598,635 casesusing the most recent data from the NationalCancer Data Base (NCDB), ahospital-based registry held by ACS and the Commission on Cancer of theAmerican College of Surgeons. The NCDB tracks approximately 70% of thecancer cases in the United States and collects data from about 1,500hospitals. The patients included had either private insurance,Medicaid, or no insurance. The researchers also examined data from the2005 and 2006 NationalHealth Interview Survey (NHIS), a nationwidein-person survey of approximately 40,000 U.S. households conducted bythe National Center for Health Statistics (NCHS) of the Centers forDisease Control and Prevention (CDC).
For all cancers combined, the ACS researchers found thatuninsured patients were 1.6 times as likely to die within 5 yearscompared 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 usecertain health services. About 54% of uninsured patients aged 18 to 64did not have a usual source of health care. About 26% delayed care dueto cost, while nearly 23% did not get care because of cost. Anestimated 23% did not get prescription drugs because of the expense.
"For too many hardworking 'average Americans' paying forcancer treatment means not paying rent, mortgage (resulting inforeclosure or eviction), or utility bills, or even going hungry,"wrote Elmer Huerta, MD, American Cancer Society president, in anaccompanying editorial.
Discouraging Numbers
In addition to analyzing data for causal relationships, ACSresearchers focused on insurance status and cancer care among breastand colorectal cancerpatients, two of the most commonly-occurringcancers in the United States (see "WhatAre the Key Statistics for Breast Cancer?" and "WhatAre the Key Statistics for Colorectal Cancer?"). Screeningtests can often find thesecancers early, and in many cases, effective treatments are available.
Individuals with health insurance were about twice as likelyas those without to have had a recent mammogramor colorectalcancerscreening. Uninsured women were about half as likely asprivately-insured women to have received a mammogram in the past 2years, a figure that was fairly consistent across all women studied,regardless of race or ethnicity. Only about 19% of uninsured adultsaged 50 to 64 went in for a colorectal cancer screening test, comparedto about 48% of those with private insurance. People with insurancewere also more likely to be diagnosed with early stage disease and lesslikely to be diagnosed with advanced stage disease than the uninsured.
The researchers saw a survival difference in breast andcolorectal cancer, too. About 89% of privately insured white women withbreast cancer survived at least 5 years, compared to 76% of white womenwith Medicaid or no insurance. Among African-American women, 81% ofbreast cancer patients with private insurance survived 5 years,compared to 65% of those on Medicaid and 63% of those withoutinsurance. A similar pattern emerged in colorectal cancer. Among whitepatients with private insurance, 66% survived 5 years, compared to 50%of those with no insurance and 46% of those on Medicaid. Among AfricanAmericans, 60% with private insurance survived 5 years compared to 41%of the uninsured and Medicaid patients.
Barriers to Care
The risk of being uninsured or underinsured varies.
Adults aged 18 to 24 have the highest probability of beinguninsured, and African Americans, Hispanics, Asian American/PacificIslanders, and American Indian/Alaska Natives are much more likely tobe uninsured than non-Hispanic whites.
"It's important to note that although variations in health insurancecoverage likely contribute to racial and ethnic disparities in canceroutcomes, those disparities persist for several outcomes even whendifferences in insurance status are accounted for," said ElizabethWard,PhD, the report's lead author. "So even if health insurance andfinancial barriers can be overcome, further research and interventionswill be needed to address these other barriers."
Almost anyone can be underinsured in the event of a majorillness. The underinsured, commonly defined as people who spend morethan 10% of their after-tax household income on out-of-pocket expensesin the event of a serious illness, often don't realize the gravity oftheir situation until faced with high premiums and deductibles, limits onterms for covered services, and caps on monthly, lifetime, ordisease-specific coverage.
According to a 2003 study sponsored by the Agency for HealthCare Research and Quality, the prevalence of being underinsuredincreased from 6.7% to 8.5% among nonelderly adults between 1996 and2003. These numbers shot up when the costs of health insurance premiumswere factored in. Among people with cancer, 29% had out-of-pocketexpenses that exceeded 10% of their family's income and about 11%exceeded it by 20%.
In 2007, the American Cancer Society launched the Accessto Care campaign, a national initiative dedicated to raisingawareness aboutthe plight of uninsured and underinsured people in the United States.The campaign encourages Americans to get involved in finding ways tofix the problem and make access to care a national priority.
Citation: "Association of Insurance with Cancer CareUtilization and Outcomes." Published online Dec. 20, 2007,and in theJan/Feb 2008 issue of CA:A Cancer Journal for Clinicians (Vol. 58, No.1).First author: Elizabeth Ward, PhD, American Cancer Society.