Does increasing insurance improve outcomes for US cancer patients?

doi:10.1016/j.jss.2013.05.058

Journal of Surgical Research

Volume 185, Issue 1, November 2013, Pages 15-20

https://doi.org/10.1016/j.jss.2013.05.058 Get rights and content

Abstract

Background

Although debate continues on US healthcare and insurance reform, data are lacking on the effect of insurance on community-level cancer outcomes. Therefore, the objective of the present study was to examine the association of insurance and cancer outcomes.

Materials and methods

The US Census Bureau Current Population Survey, Small Area Health Insurance Estimates (2000) were used for the rates of uninsurance. Counties were divided into tertiles according to the uninsurance rates. The data were compared with the cancer incidence and survival for patients residing in counties captured by the Surveillance, Epidemiology, and End Results database (2000–2006). Aggregate patient data were collected of US adults (aged ≥18 y) diagnosed with the following cancers: pancreatic, esophageal, liver or bile duct, lung or bronchial, ovarian, colorectal, breast, prostate, melanoma, and thyroid. The outcomes included the stage at diagnosis, surgery, and survival. Univariate tests and proportional hazards were calculated.

Results

The US uninsurance rate was 14.2%, and the range for the Surveillance, Epidemiology, and End Results counties was 8.3%–24.1%. Overall, patients from lower uninsurance rate counties demonstrated longer median survival. Adjusting for patient characteristics and cancer stage (for each cancer), the patients in the higher uninsurance rate counties demonstrated greater mortality (8%–15% increased risk on proportional hazards). The county uninsurance rate was associated with the stage at diagnosis for all cancers, except pancreatic and esophageal, and was also associated with the likelihood of being recommended for cancer-directed surgery (for all cancers).

Conclusions

Health insurance coverage at a community level appears to influence survival for patients with cancer. Additional investigations are needed to examine whether individual versus community associations exist and how best to surmount barriers to cancer care.

Introduction

A significant debate regarding US healthcare reform is ongoing, including increasing access to health insurance for all citizens. Nothing has highlighted this more than the recent passage of the Affordable Care Act, subsequent Supreme Court ruling in its favor, and ongoing congressional disputes. Regardless of the arguments surrounding the best methods to implement coverage, health insurance has long been linked to positive outcomes for many diseases. The effect insurance coverage has on cancer outcomes might not be as completely understood. Cancers vary in outcomes in part because of variations and disparities in screening and diagnostic availability, biology, and treatment strategies. Therefore, we sought to investigate the effect of health insurance coverage, at a community level, on the outcomes in cancer care. We hypothesized that health insurance coverage would lead to improved outcomes for patients with cancer, although the effect might vary depending on the lethality of the cancer.

The Institute of Medicine has cited a 25% increased risk of death for those who are uninsured compared with those with private health insurance [1]. A study of the National Cancer Database for outcomes in 12 cancers found that patients who were uninsured or had Medicaid insurance might be diagnosed with more advanced disease than privately insured patients and therefore would have an associated worse survival, although this was not found to be statistically significant for pancreatic and ovarian cancer [2].

The objective of our study was to focus on the interplay between health insurance coverage and cancer survival. First, on a national level, we examined the uninsurance rates for the United States as a whole, then state-by-state, and, finally, at the county level. We then specifically studied cancer survival compared with the associated uninsurance rate of each county.

Section snippets

Data resources

Data regarding uninsurance percentages were obtained from the Current Population Survey, Annual Social and Economic Supplements (2000–2002) and the Small Area Health Insurance Estimates (2000) from the US Census Bureau. The Annual Social and Economic Supplement to the Current Population Survey is a survey of approximately 78,000 households that collects health insurance information for every household resident [3]. The Small Area Health Insurance Estimates program includes data on health

Uninsurance and overall survival

The US uninsurance rate for 2000–2002 was 14.7%, with range across the states of 8.3%–24.1% [12] and across counties matched for SEER registry areas of 4.4%–34.3% [13]. Counties with lower rates of uninsured populations (i.e. highly insured counties) had associated increased 5-y survival rates and median survival among all cancer types (Table 1). Kaplan-Meier survival analyses demonstrated small, but significant, differences in median survival time and overall survival across the county

Discussion

We have found that across the United States, insurance coverage within a given community correlated with improved cancer outcomes. More highly insured counties demonstrated increased 5-y and/or median survival. The survival curves for all cancers consistently demonstrated higher survival among populations from counties with more insurance coverage. Furthermore, adjusting for patient characteristics and cancer stage, increased county-wide uninsurance rates conferred an increased risk of

Acknowledgment

This work was supported by a Howard Hughes Medical Institute Early Career Award, the American Cancer Society (grant MRSG-10-003-01-CPHPS), and the American Surgical Association Foundation Fellowship (all to Dr Tseng).

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A total of 572 patients with sPMBT (Medicaid: 59, non-Medicaid: 513) were identified. Medicaid patients were more likely to be younger (P < 0.001), Black (P < 0.001), live in high poverty neighborhoods (P = 0.006), have distant metastases at diagnosis (P < 0.001), and less likely to receive surgery (P = 0.006). The 5-year survival rate was 65.7% (chondrosarcoma: 70.0%, chordoma: 91.5%, Ewing sarcoma: 44.6%, GCT: 90.0%, osteosarcoma: 34.2%). Medicaid patients had significantly worse 5-year survival than non-Medicaid patients (52.0% vs. 67.2%, P = 0.02). Minority individuals on Medicaid were associated with an increased risk of cancer-specific mortality compared with White non-Medicaid patients (adjusted hazard ratio [aHR] = 2.51, [95% CI 1.18–5.35], P = 0.017). Among Medicaid patients, those who received surgery had significantly better survival than those who did not (64.5% vs. 30.6%, P = 0.001). For all patients, not receiving surgery (aHR = 1.90 [1.23–2.95], P = 0.004) and tumor diameter >50 mm (aHR=1.89 [1.10–3.25], P = 0.023) were associated with an increased risk of mortality.
Medicaid patients may be less likely to receive surgery and suffer from poorer survival. These disparities may be especially prominent among minorities.
Disparities in primary pancreatic adenocarcinoma survival by Medicaid-status: A national population-based risk analysis; Impact of Medicaid on primary pancreatic adenocarcinoma survival
2023, European Journal of Surgical Oncology
Pancreatic adenocarcinoma (PAC) has one of the highest mortality rates among all malignancies. While previous research has analyzed socioeconomic factors’ effect on PAC survival, outcomes of Medicaid patients are understudied.
Using the SEER-Medicaid database, we studied non-elderly, adult patients with primary PAC diagnosed between 2006 and 2013. Five-year disease-specific survival analysis was performed using the Kaplan-Meier method and adjusted analysis using Cox proportional-hazards regression.
Among 15,549 patients (1799 Medicaid, 13,750 non-Medicaid), Medicaid patients were less likely to receive surgery (p < .001) and more likely to be non-White (p < .001). The 5-year survival of non-Medicaid patients (8.13%, 274 days [270–280]) was significantly higher than that of Medicaid patients (4.97%, 152 days, [151–182], p < .001). Among Medicaid patients, those in high poverty areas had significantly lower survival rates (152 days [122–154]) than those in medium poverty areas (182 days [157–213], p = .008). However, non-White (152 days [150–182]) and White Medicaid patients (152 days [150–182]) had similar survival (p = .812). On adjusted analysis, Medicaid patients were still associated with a significantly higher risk of mortality (aHR 1.33 [1.26–1.41], p < .0001) compared to non-Medicaid patients. Unmarried status and rurality were associated with a higher risk of mortality (p < .001).
Medicaid enrollment prior to PAC diagnosis was generally associated with a higher risk of disease-specific mortality. While there was no difference in the survival between White and non-White Medicaid patients, Medicaid patients living in high poverty areas were shown to be associated with poor survival.
Health Care Disparities and the Future of Pancreatic Cancer Care
2021, Surgical Oncology Clinics of North America
Citation Excerpt :
As the disease-associated morbidity and the toxicity of available therapies become greater, the influence of social determinants of health on tolerance and success of treatment becomes more powerful. To further complicate matters, pancreatic cancer disproportionately affects nonwhite, lower income, and uninsured populations.4–6 This disparity ultimately translates to worse outcomes for these patients.7
The impact of demographics, socioeconomics, and health care access on melanoma outcomes
2021, Journal of the American Academy of Dermatology
Disparities in melanoma care exist in the United States. Disparities in provider type, patient demographics, place of residence, insurance status, socioeconomic status, race/ethnicity, and age impact melanoma outcomes. Melanomas detected by dermatologists are thinner, at an earlier stage, and have better survival outcomes compared with detection by primary care providers or patients. Lower socioeconomic status, race/ethnicity, and place of residence are associated with decreased access to or use of dermatologists, or both, and more advanced melanomas at diagnosis. Additionally, uninsured and publicly insured individuals are more likely to present with late-stage melanomas, resulting in worse outcomes. This review provides a comprehensive overview of how structural and patient-level characteristics influence melanoma outcomes in order to inform clinical care and health care policy as it relates to addressing gaps in melanoma care.
Insurance status is related to overall survival in patients with small intestine adenocarcinoma: A population-based study
2020, Current Problems in Cancer
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There could be multiple factors explaining why insured patients exhibit better survival, but one assumption is that the insurance status indirectly indicates the socioeconomic status, patients with good financial skills and social support may receive high quality home and hospital care, which may improve survival. Previous research has observed that outcomes in cancer patients are better among those with insurance coverage, one important explanation is that uninsured patients may postpone visiting physicians because of the costs related, and that on itself may postpone diagnosis and worsen survival.11,19,20 It has been demonstrated that living in rural and poor areas is associated with being uninsured,21 and economic constraints make uninsured patients less likely to receive recommended surgical interventions.
Background: Our goal was to investigate the effect of insurance status on the overall survival (OS) in cases of small intestine adenocarcinoma.
Methods: The SEER (Surveillance, Epidemiology, and End Results) database was used to identify 3822 patients who were diagnosed with small intestine adenocarcinoma between 2007 and 2015. The proportional hazard ASSUMPTION was evaluated by proportional-hazards assumption test and Schoenfeld residual test. The Kaplan-Meier method and Cox proportional-hazards regression analysis were performed to evaluate the association between insurance status and OS.
Results: We found that the insurance status at the time of diagnosis affected OS at the population level, both in those aged <65 and ≥65 years. Cox multivariate analysis of patients aged <65 years revealed that the hazard of death was greater in the Medicaid group (hazard ratio [HR] = 1.641, 95% confidence interval [CI] = 1.299-2.073, P < 0.001] and uninsured group (HR = 1.472, 95% CI = 1.095-1.979, P = 0.010) compared with the insured group, while the OS did not differ significantly between the Medicaid and uninsured groups. Similarly, the hazard of death among patients aged ≥65 years was higher in the Medicaid than the insured group (HR = 1.403, 95% CI = 1.136-1.733, P = 0.002).
Conclusion: Our results suggest that patients with small intestine adenocarcinoma with insurance coverage have a significantly better OS than patients who have Medicaid or are uninsured, while the OS does not differ between Medicaid and uninsured patients.
Health Changes in Low Income Men Transitioning from a State Funded Prostate Cancer Program to Comprehensive Insurance
2018, Journal of Urology
We evaluated the effect of transitioning from a prostate cancer specific treatment program to comprehensive insurance under the ACA (Patient Protection and Affordable Care Act) on the physical, mental and prostate cancer related health of poor, previously uninsured men.
We assessed general and prostate cancer specific health related quality of life using the RAND SF-12v2™ (12-Item Short Form Survey, version 2) and the UCLA PCI (Prostate Cancer Index) at 3 time points in 24 men who transitioned to comprehensive insurance as the insured group relative to 39 who remained in the prostate cancer program as the control group. We used mixed effects models controlling for treatment and patient factors to measure health differences between the groups during the transition period.
Demographics, prostate cancer treatment patterns, and mental, physical and general health were similar before transition in the control and insured groups. After transition men who gained insurance coverage reported significantly worse physical health than men who remained in the prostate cancer program (p = 0.0038). After adjustment in the mixed effects model physical health remained worse in men who gained insurance (p = 0.0036). Mental health and prostate cancer related quality of life did not differ with time between the groups.
Compared to controls who remained in the state funded prostate cancer treatment program for poor, uninsured men, newly insured men reported worse physical health after transitioning to ACA coverage. Providers and policy makers may draw important lessons from understanding the mechanisms of this paradoxical worsening in physical health after gaining insurance. These results inform the development of disease specific models of care in the broader health insurance context.

View all citing articles on Scopus

: This work was presented in part at the 2010 American Society of Clinical Oncology Annual Meeting, June 5, 2010; in part at the American College of Surgeons Surgical Forum, October 7, 2010; and in part at the Association for Academic Surgery Academic Surgical Congress, February 3, 2011.

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Association for Academic SurgeryDoes increasing insurance improve outcomes for US cancer patients?

Abstract

Background

Materials and methods

Results

Conclusions

Introduction

Section snippets

Data resources

Uninsurance and overall survival

Discussion

Acknowledgment

Lancet Oncol

Surg Oncol Clin North Am

Care without coverage: too little, too late

Nonparametric estimation from incomplete observations

J Am Stat Assoc

The robust inference for the Cox proportional hazards model

J Am Stat Assoc

Association for Academic Surgery
Does increasing insurance improve outcomes for US cancer patients?