Cancer Prevention and the Uninsured

Advances in science have improved our ability to prevent cancer, screen for precancerous conditions or early stage disease, and treat cancers when they occur. These improvements have extended the lives of millions of Americans. Most of these preventive, screening, and treatment interventions, however, are costly services delivered by medical providers. Americans who cannot pay for these services do not benefit equally from these scientific improvements. Chief among this group are the over 46 million Americans who lacked health insurance coverage in 2006.(1)

Almost all Americans over 65 years of age have health insurance coverage for medical and hospital services and, with the passage of Medicare Part D, most have prescription drug coverage available as well. This coverage improves access and reduces out-of-pocket costs for the 56% of cancer patients who are diagnosed after age 64.(2) The remaining 44% of cancer diagnoses, as well as most preventive and screening services, occur among people under age 65; about 18% in this group lack health insurance.(1)

Most people 65 years and under obtain coverage through their jobs but over 60% of uninsured people are full-time workers or family members of such workers.(1) Some of those who do not obtain coverage in their jobs are eligible for coverage through public programs. Medicaid, a federal-state program with eligibility rules that vary by state, provides insurance coverage to low income children and to a very limited group of low income adults. Medicare provides coverage to permanently disabled adults under 65. Finally, individuals may purchase non-group coverage, but insurance in this market is likely to be costly and is often unavailable to those in less than excellent health, including those with prior cancer diagnoses.

Lack of insurance coverage impedes access to the full range of cancer-related medical services. Insurance coverage reduces the cost of receiving behavioral counseling or prevention services, including services aimed at improving diet or reducing tobacco use. It also improves access to cancer screening, including genetic screening.

In general, people without coverage use about half as much care as do people with insurance coverage.(3) They are over one-third less likely to see a physician each year.(4) Physician visits--even visits for common symptoms unrelated to cancer--are an important locus for behavioral counseling and an opportunity for physicians to recommend appropriate screening tests. (5)

People without coverage are far less likely to obtain appropriate cancer screening tests (6). For example, in 2004, uninsured people over age 50 were less than half as likely as insured people in the same age group to have received appropriate colon cancer screening.(7) Substantial efforts have gone into improving cervical and breast cancer screening for the population. Nonetheless, in 2004, uninsured women were about 14% less likely to have had age-appropriate screening for these malignancies.(7) In addition to reduced rates of use of specific cancer screening tests, uninsured people also report that they often delay seeking care for a range of symptoms, that, in a few cases, may indicate the presence of cancer.(1) In this way, these delays may contribute to later diagnoses of other cancers.

Once diagnosed, uninsured people with cancer use significantly fewer inpatient and outpatient visits as do comparable patients with the same cancers who have insurance coverage, and they are more likely to report delays in medical care or failure to receive appropriate therapy. These differences in screening and treatment lead to significant differences in mortality for insured and uninsured people. The Institute of Medicine has estimated that lack of insurance coverage increases the odds of overall mortality by 25%.(8) Studies that examine people with cancer find adjusted risks of death as much as nearly 50% higher for uninsured breast cancer patients and 40% higher for uninsured colon cancer patients, than among their privately insured counterparts. (9-10)

A variety of sources provide some access to cancer screening and treatment services for people without insurance coverage. The National Breast and Cervical Cancer Early Detection Program, a Centers for Disease Control and Prevention program begun in 1991, provides free screening for these cancers for age-defined populations. All states currently participate in the program, but coverage varies among the states. After introducing the program, however, policymakers and advocates realized that screening people for cancer was not an effective prevention strategy unless treatment was available to those who screened positive. People who do not believe they can afford treatment are less likely to seek screening.(11) Thus, in 2000, Congress passed the Breast and Cervical Cancer Prevention and Treatment Act (BCCPT), which permits states to provide presumptive eligibility for Medicaid public insurance coverage to those who screen positive through the early detection program. Most, but not all, states participate in this program, and benefits vary among the states.(6,12) A few states have extended their screening efforts beyond these Federal programs. For example, since 1997, New York State’s Colorectal Cancer Screening and Prostate Initiative Program has provided colorectal cancer screening to uninsured (and underinsured) people in many counties. In July 2006, New York State passed the Colon-Prostate Treatment Act, the first program in the nation to fund treatment for colon cancers identified through the state screening program. (13)

Unfortunately, advances in the prevention, detection, and treatment of cancer have often had the effect of exacerbating access problems for uninsured people. New forms of screening, including genetic screening, are often more costly than existing screens, making financial access to care more difficult. More cancer treatment is being provided in outpatient settings, rather than in hospitals, and mechanisms to finance the care of uninsured people are less well established in these settings(14). Many treatment advances involve the use of new pharmaceuticals, which are often costly and, in some cases, must be used for extended periods of time. Although pharmaceutical companies often provide some access under compassionate use policies, this source of financing is not always available.

People without health insurance may find it prohibitively costly to obtain routine cancer screening. Moreover, they may view screening and early diagnosis as less of a priority if they are not confident that they can obtain care if they screen positive. As Congress learned after passing the BCCPT, addressing access to cancer prevention requires also ensuring that patients have access to cancer treatment. And, as the Institute of Medicine concluded, people without coverage receive care that is “too little, too late."(8)

References

1. Kaiser Commission on Medicaid and the Uninsured. The Uninsured: A Primer. October 2006. Washington, DC: Kaiser Family Foundation
2. Ries, L. et al. SEER Cancer Statistics Review, 1975-2003, seer.cancer.gov/csr/1973_1999, Tables I-10.
3. Hadley J, Holahan J. How much medical care do the uninsured use, and who pays for it? Health Affairs, 2003 12 February, Web exclusive.
4. Taylor A, Cohen J, Machlin S. Being uninsured in 1996 compared to 1987: how has the experience of the uninsured changed over time? Health Service Research. 2001; 36:16-31.
5. Fox SA, Murata PJ, Stein JA. The impact of physician compliance on screening mammography for older women. Arch Intern Med. 1991;151:50-56.
6. Breen N and Meissner HI. Toward a System of Cancer Screening in the US: Trends and Opportunities. Ann Rev Publ Health. 2005; 26: 561-582.
7. Author’s tabulations of the 2004 Behavioral Risk Factor Surveillance System.
8. Institute of Medicine, Care without Coverage: Too Little, Too Late, Washington, D.C.: National Academy Press. 2002.
9. Ayanian JZ, Kohler BA, Abe T, et al. The relation between health insurance coverage and clinical outcomes among women with breast cancer. NEJM. 2003;329:326-331.
10. Kelz RR, Gimotty PA, Polsky D, et al. Morbidity and mortality of colorectal carcinoma surgery differs by insurance status. Cancer.2004;101:2187-2194.
11. O’Malley AS, Beaton E, Yabroff KR, et al. Patient and Provider barriers to colorectal cancer screening in the primary care safety net. Preventive Medicine. 2004; 39:56-63.
12. www.health.state.ny.us/nysdoh/bcctp/bcctp.htm
13. Choi C. Treatment for colon, prostate cancers covered under new law. The Associated Press State and Local Wire, July 27, 2006
14. Glied S, Little SA. The Uninsured and the benefits of medical progress. Health Affairs. 2003;22:210-219.