Does access to insurance always translate to access to cancer care? The unfortunate reality in the United States is that health outcomes in patients with cancer rely heavily on whether a person has private insurance, public insurance, or is underinsured or uninsured, according to Amy Davidoff, PhD, MS, social and behavioral scientist administrator at the National Cancer Institute.
Navigating the health insurance landscape in the United States is confusing—and particularly so in light of the ever-changing expansions under the Affordable Care Act (ACA)—but understanding the many existing disparities in cancer-related care and coverage can help providers to offer the best care possible to their patients and to find solutions for those who might be getting left behind.
“Unlike some countries that provide national health insurance, or at least ensure that everyone has it, we tend to use health insurance as kind of a policy lever to give some people more access than others,” said Dr Davidoff at the 2022 Summit on Cancer Health Disparities in Seattle, WA. “This is done through tax policy, regulatory policy, and budgets to start and continue new programs that provide insurance, like Medicare and Medicaid. So it’s important to pay attention to how it is used in our country.”
To define it broadly, insurance makes certain that providers get paid for care delivery and provides a level of financial protection for the consumer/patient at the point of care. But research has consistently proved that receipt of recommended cancer screenings like Pap smears, mammograms, and colonoscopies varies widely by insurance coverage and type.
A pre-ACA study showed that privately insured individuals are the least likely to have a late-stage cancer diagnosis, followed by those with public insurance, and unsurprisingly, the uninsured.
However, Dr Davidoff noted that the odds of advanced-stage diagnosis were not particularly different in people with Medicaid versus uninsured individuals, and receipt of recommended cancer-directed surgery was actually lower in patients with Medicaid compared with the uninsured.
“Insurance coverage in the US is very important, but it’s not sufficient, and not all insurance is created equal,” she said. “Variations exist according to the type of cancer a person has, but the pattern is the same: a better experience for those with private insurance.”
The balance of provider access (ie, network restrictions, network size) versus patient financial protection (ie, scope and depth of coverage, deductibles, copays, out-of-pocket max) also varies widely according to insurance type. Medicaid provides a high level of financial protection but restricted provider access. Medicare has ample provider access but subpar financial protection compared with Medicaid. Medicare in combination with private insurance offers high levels of both financial protection and provider access, while again, the uninsured have neither.
Medicaid and Other Expansions Under the ACA
“The ACA had very lofty goals of improving health, healthcare quality and equity, and reducing costs,” she said.
Using a multilayered approach, these goals centered around expanding public insurance, improving access to private insurance (while reducing expenses), and generally improving healthcare access for all people while cutting down on out-of-pocket costs.
After its implementation, several expansions to the ACA were put in place, but the biggest and most notable was the expansion of Medicaid. The initial goal of this expansion was to provide uniform Medicaid eligibility for all adults under the age of 65 years with income under 138% of the federal poverty level, including those without dependent children who were typically excluded from the Medicaid program before the ACA.
“This benefited people about 40 to 64 years old in whom cancer incidence is starting to tick upwards, but their kids are grown and out of the house, making them no longer eligible for Medicaid,” she explained. “But unfortunately, the mandatory nature of the expansion was undermined with the Supreme Court decision in 2012, making it a voluntary expansion.”
Currently, 39 states (including Washington, DC) have adopted the Medicaid expansion decision, with most of those who opted out clustered in the Southeast (as well as Texas, Kansas, Wyoming, South Dakota, and Wisconsin).
While insurance marketplaces and expansions to private insurance also resulted in lower rates of uninsured people in the United States, the individual insurance mandate was no longer enforced beginning in 2019, leading to increases in the number of uninsured yet again.
Effects of the ACA on Disparities in Insurance Coverage
“The goal of the ACA was universal coverage, but we knew that was never possible,” said Dr Davidoff.
While more research is needed on the effects of ACA-related coverage on cancer-related care during treatment, survivorship, and end of life, ACA expansions have undoubtedly led to small but incremental improvements.
Primarily through the expansion of Medicaid, the ACA reduced uninsurance among all racial and ethnic groups (with black and Hispanic adults experiencing larger decreases in uninsurance). Prior to the ACA, uninsured rates for adults aged 19 to 64 years varied substantially by race and ethnicity, with black and Hispanic people making up the highest proportion of uninsured.
However, a tremendous number of people in the United States remain uninsured today, and disparities still exist, she noted.
According to Dr Davidoff, a number of studies have looked at the impact of the ACA on cancer screenings and found varying degrees of success, but research has shown that ACA insurance expansions led to an uptick in certain cancer screenings. One study showed a trend toward overall improvement in colorectal cancer screening; in contrast, few significant changes were seen in mammography during the same period, possibly due to existing free or reduced-price access to mammography in the community.
Increased access to screening has also led to small but important changes in stage at cancer diagnosis: a study using SEER registry data demonstrated that the Medicaid expansion was associated with an increase in early-stage diagnoses in 2014, as well as a decrease in late-stage diagnoses, but not until 2016.
“So there is some shift in the stage at which people are diagnosed, related presumably to increased access to screening and also to primary care,” she noted.
Although racial/ethnic differences in advanced-stage cancer diagnosis and 5-year survival do remain, ACA expansions were associated with reduced disparities in the rate of timely treatment (≤30-day delay) received by black versus white patients.
“Prior to the expansion, white patients were much more likely than black patients to receive care in a timely manner; after the expansion, that gap almost entirely disappeared and is no longer significant,” she reported. “That’s a narrow—but important—slice of the picture.”
Dr Davidoff noted that more research is needed on provider access and quality of care for adults enrolled in Medicaid, as well as on disparities related not only to race/ethnicity but also to socioeconomic status and urban versus rural residence.
“Despite these little snippets where we can demonstrate an improvement in care, disparities still remain,” she said. “Insurance is very much enmeshed in a number of social and economic risk factors that likely impact access to cancer care, and further research on these is needed.”