In the JournalsPerspective

Health insurance coverage varies by patient demographics, cancer type

The rates of health insurance coverage for patients with cancer tend to vary based on patient demographics and their cancer type, according to study results.

These findings suggest that expanded coverage as part of the Affordable Care Act may result in disproportionate benefits to certain patient populations, according to the researchers.

Approximately 48 million Americans have no health insurance, according to study background. Usama Mahmood, MD, assistant professor in the department of radiation oncology in the division of radiation oncology at The University of Texas MD Anderson Cancer Center, and colleagues sought to examine how insurance coverage differs among nonelderly patients with cancer according to various factors such as race, age, gender, cancer type, marital status and rural vs. urban residence.

The researchers identified 688,794 patients from the SEER database aged 18 to 64 years who were diagnosed between 2007 and 2010 with one of the top 25 most frequently diagnosed cancers. The researchers classified patients as uninsured, having Medicaid or having non-Medicaid insurance.

Data indicated that younger age, male sex, nonwhite race, being unmarried, residence in counties with higher levels of poverty and rural residence were associated with being uninsured vs. having non-Medicaid insurance (P < .001 for all).

The highest rates of non-Medicaid insurance occurred among patients with prostate cancer (92.3%), melanoma of the skin (92.5%) and thyroid cancer (89.5%), whereas the lowest rates for  non-Medicaid insurance occurred among patients with cervical cancer (64.2%), liver cancer (67.9%) and stomach cancer (70.9%; P < .001 for all).

The most prevalent cancers among patients without insurance were lung cancer (14.9%), colorectal cancer (12.1%) and breast cancer (10.2%; P < .001 for all).

Lung cancer was the leading cause of death among all insurance groups.

“Both insurance status and type of cancer are affected by demographic factors,” Mahmood said in a press release. “It was interesting to see how each varies with the other.”

The researchers concluded that the association between tumor site and insurance status had three possible contributing factors:

  • Uninsured patients are less likely to use cancer screening tests.
  • The association between younger age and no insurance contributes to age-associated cancers. Thus, a cancer such as testicular cancer (median age at diagnosis, 33 years) is more prevalent among uninsured patients, whereas prostate cancer (median at diagnosis, 66 years) is more prevalent among insured patients. 
  • A lack of insurance is associated with cancer risk factors, such as tobacco use and alcohol abuse.

The investigators noted that because income is not reported in SEER, the data instead included county-level income data as a measure of socioeconomic status. Also, identifying insurance status is new to SEER — which does not create subsets among privately insured patients — and, therefore, could lead to misclassification in some instances. Finally, 6.1% of the cohort had an unknown insurance status.

“Further research will be required to determine how changes in health care coverage impact the presentation, treatment and survival of cancer patients,” Mahmood said in the release.

Overall, these data may suggests certain implications of the Patient Protection and Affordable Care Act (PPACA), according to the researchers.

“Rates of insurance vary greatly by patient demographic factors and by cancer type, suggesting that the expansion of coverage under the PPACA will likely disproportionately impact certain patient populations with cancer more greatly than others,” Mahmood and colleagues concluded. “The effect on quality of care and outcomes remains to be seen.” – by Anthony SanFilippo

Disclosure: The researchers report no relevant financial disclosures.

The rates of health insurance coverage for patients with cancer tend to vary based on patient demographics and their cancer type, according to study results.

These findings suggest that expanded coverage as part of the Affordable Care Act may result in disproportionate benefits to certain patient populations, according to the researchers.

Approximately 48 million Americans have no health insurance, according to study background. Usama Mahmood, MD, assistant professor in the department of radiation oncology in the division of radiation oncology at The University of Texas MD Anderson Cancer Center, and colleagues sought to examine how insurance coverage differs among nonelderly patients with cancer according to various factors such as race, age, gender, cancer type, marital status and rural vs. urban residence.

The researchers identified 688,794 patients from the SEER database aged 18 to 64 years who were diagnosed between 2007 and 2010 with one of the top 25 most frequently diagnosed cancers. The researchers classified patients as uninsured, having Medicaid or having non-Medicaid insurance.

Data indicated that younger age, male sex, nonwhite race, being unmarried, residence in counties with higher levels of poverty and rural residence were associated with being uninsured vs. having non-Medicaid insurance (P < .001 for all).

The highest rates of non-Medicaid insurance occurred among patients with prostate cancer (92.3%), melanoma of the skin (92.5%) and thyroid cancer (89.5%), whereas the lowest rates for  non-Medicaid insurance occurred among patients with cervical cancer (64.2%), liver cancer (67.9%) and stomach cancer (70.9%; P < .001 for all).

The most prevalent cancers among patients without insurance were lung cancer (14.9%), colorectal cancer (12.1%) and breast cancer (10.2%; P < .001 for all).

Lung cancer was the leading cause of death among all insurance groups.

“Both insurance status and type of cancer are affected by demographic factors,” Mahmood said in a press release. “It was interesting to see how each varies with the other.”

The researchers concluded that the association between tumor site and insurance status had three possible contributing factors:

  • Uninsured patients are less likely to use cancer screening tests.
  • The association between younger age and no insurance contributes to age-associated cancers. Thus, a cancer such as testicular cancer (median age at diagnosis, 33 years) is more prevalent among uninsured patients, whereas prostate cancer (median at diagnosis, 66 years) is more prevalent among insured patients. 
  • A lack of insurance is associated with cancer risk factors, such as tobacco use and alcohol abuse.

The investigators noted that because income is not reported in SEER, the data instead included county-level income data as a measure of socioeconomic status. Also, identifying insurance status is new to SEER — which does not create subsets among privately insured patients — and, therefore, could lead to misclassification in some instances. Finally, 6.1% of the cohort had an unknown insurance status.

“Further research will be required to determine how changes in health care coverage impact the presentation, treatment and survival of cancer patients,” Mahmood said in the release.

Overall, these data may suggests certain implications of the Patient Protection and Affordable Care Act (PPACA), according to the researchers.

“Rates of insurance vary greatly by patient demographic factors and by cancer type, suggesting that the expansion of coverage under the PPACA will likely disproportionately impact certain patient populations with cancer more greatly than others,” Mahmood and colleagues concluded. “The effect on quality of care and outcomes remains to be seen.” – by Anthony SanFilippo

Disclosure: The researchers report no relevant financial disclosures.

    Perspective
    Blase N. Polite

    Blase N. Polite

    Grant and colleagues take advantage of the addition of insurance status to the SEER database starting in 2007 to describe the sociodemographic characteristics of non-Medicaid insured, uninsured and Medicaid-insured patients with cancer, as well as to elaborate on the cancer burden in this group. Their analysis covers the period from 2007 to 2010 for individuals aged 18 to 64 years, which provides a nice snapshot of the pre-Affordable Care Act adult cancer population.
    Their first set of findings, although important, are already well known to health policy experts: The uninsured, whether with cancer or not, are more likely to be young, single, nonwhite, poor and male. Medicaid follows a similar pattern, with the exception of female predominance owing to eligibility design that favors single women with children.
    Their second set of findings hold more interest. Within each of the three insurance groups — non-Medicaid insured, uninsured and Medicaid — Grant and colleagues look at cancer prevalence and cancer mortality. They also look at insurance status for each type of cancer.
    The most interesting way to view their data is to look at which cancers appear in some groups but not others. For example, colorectal cancer is on the top three list of prevalent cancers for Medicaid and uninsured patients but is not on the non-Medicaid insured list. Similarly, patients with cervical cancer have high rates of uninsurance and Medicaid but have very low rates of non-Medicaid insurance. Of course, both of these cancers have recommended screenings that detect precancerous lesions, providing further evidence of the importance of adequate insurance in preventing these cancers. Prostate cancer, on the other hand, is well represented among the non-Medicaid insured, both as a cancer where the majority of patients have insurance and as being very prevalent in this group. It does not show up on list for the other insurance groups, and for none of the three groups is it a major cause of death.
    Part of this is no doubt an age phenomenon, as the uninsured and Medicaid patients are likely to be younger. But there is perhaps more to this story, as colorectal cancer also has a similar median age incidence as prostate cancer. Being well insured certainly leads to better screening for all cancers, but not getting screened for prostate cancer does not lead to it being more prevalent in the Medicaid or uninsured group, suggesting that it likely remains asymptomatic if it is present. Further, the lack of detection is not causing undue mortality, suggesting that population screening for prostate cancer may not be necessary — a point that has been well argued by many.
    Although this study tells us mostly what we already know, it is important to be reminded that not having adequate insurance — even among the young and invincible — is a recipe for getting and dying of preventable cancers.

    • Blase N. Polite, MD, MPP
    • HemOnc Today Editorial Board member The University of Chicago Medicine

    Disclosures: Polite reports no relevant financial disclosures.