Underinsured Means Unprotected
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By Robin Mejia

Underinsured Means Unprotected

Lack of insurance coverage linked to late-stage cancers

By Robin Mejia


Most cancer prevention campaigns try to get people to change their personal behavior, whether that means eating more vegetables or scheduling that colonoscopy. So when the American Cancer Society (ACS) recently decided to focus its entire advertising budget on the need for affordable health coverage for all Americans, it was so unusual a move that it was covered widely by news media outlets, including the New York Times and CR.

Now ACS researchers have published a study that supports the organization’s decision. People who don’t have insurance or have Medicaid are more likely to be diagnosed with a late-stage cancer than people with private insurance, according to the findings, published online Feb. 18 in the Lancet Oncology. The researchers analyzed data on more than 3.7 million patients from around the country, many of them at community hospitals and cancer centers, which treat most cancer patients. The study examined the patients’ ethnicity, insurance status, and how far their cancer had progressed at the time of their diagnosis. It found that patients with no insurance or Medicaid coverage were more than twice as likely to have an advanced-stage cancer at the time they were diagnosed than those with private insurance or Medicare.

“One of the most compelling aspects of this study is that it includes hospitals from across the country that care for 75 percent of cancer patients,” says John Ayanian, a professor of medicine and health care policy at Harvard Medical School and a general internist at Brigham and Women’s Hospital in Boston. “Late-stage diagnosis suggests that patients haven’t been screened as they could be.”

In fact, notes Ayanian, the ACS researchers found the biggest discrepancies for cancers with early symptoms or for which good screening options exist. For example, among breast cancer patients the odds of a late-stage diagnosis were nearly three times greater for uninsured patients than for insured patients. But cancers such as pancreatic cancer, for which there is no routine screening test, tended to be diagnosed similarly among uninsured and insured patients. Insurance status has “a huge impact on the likelihood of survival” after diagnosis, notes Michael Halpern, the strategic director of health services research at the ACS and the lead researcher on the study.

Halpern and his colleagues also found that black and Hispanic patients were more likely to receive late-stage diagnoses than whites, even if they had insurance, suggesting that social or cultural factors may affect whether patients get routine screenings.

What’s more, the type of insurance a person has matters, according to the study. Medicaid patients’ diagnoses were much closer to the diagnoses of uninsured patients than to those who had private insurance or Medicare.

Medicaid is federally mandated insurance designed to cover the very poor. But unlike Medicare—a federally regulated insurance mostly for people over the age of 65—Medicaid programs are administered by the U.S. states, and rules of coverage vary. However, most Medicaid plans share some characteristics.

“Medicaid eligibility tends to be episodic,” says Halpern, noting that a patient’s eligibility for Medicaid may change month to month. This means patients are less likely to establish a relationship with a primary care physician or undergo regular screenings. In some cases Halpern examined, the cancer diagnosis itself may have triggered a patient’s enrollment in the insurance program.

“It’s not enough just to have insurance,” Halpern says. “It has to be adequate and appropriate insurance if it’s going to make a difference.”