Health Insurance Is Key to Improved Equity in Cancer Care

What Is Equity in Cancer Care?

Advances in cancer prevention, screening, and treatments have contributed to improvements in outcomes for patients with cancer. According to the American Cancer Society, the death rate from cancer decreased by 31% from 1991 to 2018 in the United States.¹

However, the benefits of these advances are not shared equally, and disparities exist in cancer outcomes by race or ethnicity, socioeconomic status, gender, and geography.

Higher socioeconomic status (health insurance, education, income, and poverty status) is associated with increased chance for survival for patients with cancer. Compared with patients who have private insurance, better education, and higher income, patients with cancer and low socioeconomic status have significantly decreased survival time from diagnosis.²

Inequity in the delivery of cancer care would lead to worse health outcomes for certain patient groups than for the rest of the population. For example, the National Cancer Institute analyzed data from 1973 to 2007 showing that black patients had higher rates of death from breast cancer, colorectal cancer, lung cancer, or prostate cancer, than white patients (in addition to other common cancers).³

Geography may also be a contributing factor for these disparities, because cancer-related death rates are higher in rural areas than in urban areas. The reason for this could be that patients living in rural areas have fewer cancer screening and treatment facilities available, which can result in being diagnosed at a later stage, have lower chance of receiving chemoradiation, and have overall higher death rates.⁴

Insurance Status Affects Equity in Cancer Care

Among the complex reasons for the disparities in cancer outcomes, limited access to health insurance plays a major role. Studies have shown the critical role of having health insurance for cancer care, including diagnosis, screening, treatment, and survival.

In the United States, people who do not have private health insurance are less likely to have access to medical care or to have screening for cancer than those with private health insurance. An analysis of nearly 4 million patients with 12 different cancer types showed that uninsured patients and those with Medicaid insurance coverage had substantially greater risks for being diagnosed with an advanced-stage cancer (when treatment is more difficult) compared with those who have private insurance.⁵

Lung cancer and colorectal cancer are the 2 leading causes of cancer-related deaths in the United States, and insurance status has the largest effect on the difference in disease stage at diagnosis, and removal of the cancer by surgery (which often cannot be done in advanced stages). A study of 6574 patients with lung cancer, and 5335 patients with colorectal cancer showed that uninsured patients had higher chances of having late-stage lung cancer or colorectal cancer than privately insured patients.⁴

Does Expanding Insurance Coverage Help?

If lacking health insurance contributes to health outcome disparities, then does improving insurance access and affordability help to address these disparities? The answer is yes—improved access to insurance contributes to earlier cancer diagnosis and improved treatment outcomes.

For example, having a more advanced stage of breast cancer at diagnosis is a major factor in the patient’s outcome disparities. A study of 177,075 patients with breast cancer showed that nearly half of the increase in late-stage diagnosis in racial or ethnic minorities was related to insurance coverage.⁶

Under the Affordable Care Act (ACA), some states expanded their Medicaid programs to cover low-income adults. For Medicaid patients in states that expanded Medicaid coverage, there was an increase in patients who were hospitalized to receive proper care and an increase in the number of patients who had surgery to remove the cancer compared with states that did not increase Medicaid coverage.⁷

In general, increasing access to health insurance increases people’s access to preventive services, which results in earlier detection of cancer and more timely and effective care for those diagnosed with cancer. In addition, improving access to health insurance contributes to the psychological well-being of patients with cancer, by knowing that they can afford care when they need it most.

References

1. American Cancer Society. Facts & Figures 2021 reports another record-breaking 1-year drop in cancer deaths. January 12, 2021. https://www.cancer.org/latest-news/facts-and-figures-2021.html.
2. Du XL, Lin CC, Johnson NJ, Altekruse S. Effects of individual-level socioeconomic factors on racial disparities in cancer treatment and survival: findings from the National Longitudinal Mortality Study, 1979-2003. Cancer. 2011;117(14):3242-3251. https://acsjournals.onlinelibrary.wiley.com/doi/10.1002/cncr.25854.
3. National Cancer Institute. SEER Cancer Statistics Review, 1975-2007. Bethesda, MD. https://seer.cancer.gov/archive/csr/1975_2007/.
4. Leech MM, Weiss JE, Markey C, Loehrer AP. Influence of race, insurance, rurality, and socioeconomic status on equity of lung and colorectal cancer care. Annals of Surgical Oncology. January 7, 2022. Epub ahead of print. https://link.springer.com/article/10.1245/s10434-021-11160-1.
5. Halpern MT, Ward EM, Pavluck AL, et al. Association of insurance status and ethnicity with cancer stage at diagnosis for 12 cancer sites: a retrospective analysis. Lancet Oncology. 2008;9(3):222-231. www.thelancet.com/journals/lanonc/article/PIIS1470-2045(08)70032-9/fulltext.
6. Ko NY, Hong S, Winn RA, Calip GS. Association of insurance status and racial disparities with the detection of early-stage breast cancer. JAMA Oncology. 2020;6(3):385-392. https://jamanetwork.com/journals/jamaoncology/fullarticle/2758266.
7. Eguia E, Cobb AN, Kothari AN, et al. Impact of the Affordable Care Act (ACA) Medicaid expansion on cancer admissions and surgeries. Annals of Surgery. 2018;268(4):584-590. www.ncbi.nlm.nih.gov/pmc/articles/PMC6675622/.