qotd: Both Medicaid and uninsured patients face disparities in care of deadly cancers

Journal of Clinical Oncology
August 4, 2014
Disparities in Stage at Diagnosis, Treatment, and Survival in Nonelderly
Adult Patients With Cancer According to Insurance Status
By Gary V. Walker, Stephen R. Grant, B. Ashleigh Guadagnolo, Karen E.
Hoffman, Benjamin D. Smith, Matthew Koshy, Pamela K. Allen and Usama Mahmood

Abstract

Purpose
The purpose of this study was to determine the association of insurance
status with disease stage at presentation, treatment, and survival among
the top 10 most deadly cancers using the SEER database.

Patients and Methods
A total of 473,722 patients age 18 to 64 years who were diagnosed with
one of the 10 most deadly cancers in the SEER database from 2007 to 2010
were analyzed. A Cox proportional hazards model was used for
multivariable analyses to assess the effect of patient and tumor
characteristics on cause-specific death.

Results
Overall, patients with non-Medicaid insurance were less likely to
present with distant disease (16.9%) than those with Medicaid coverage
(29.1%) or without insurance coverage (34.7%; P < .001). Patients with
non-Medicaid insurance were more likely to receive cancer-directed
surgery and/or radiation therapy (79.6%) compared with those with
Medicaid coverage (67.9%) or without insurance coverage (62.1%; P <
.001). In a Cox regression that adjusted for age, race, sex, marital
status, residence, percent of county below federal poverty level, site,
stage, and receipt of cancer-directed surgery and/or radiation therapy,
patients were more likely to die as a result of their disease if they
had Medicaid coverage (hazard ratio [HR], 1.44; 95% CI, 1.41 to 1.47; P
< .001) or no insurance (HR, 1.47; 95% CI, 1.42 to 1.51; P < .001)
compared with non-Medicaid insurance.

Conclusion
Among patients with the 10 most deadly cancers, those with Medicaid
coverage or without insurance were more likely to present with advanced
disease, were less likely to receive cancer-directed surgery and/or
radiation therapy, and experienced worse survival.

http://jco.ascopubs.org/content/early/2014/08/01/JCO.2014.55.6258.abstract

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Comment by Don McCanne

Clearly, insured patients with one of the most deadly cancers have
better outcomes than uninsured patients. Of concern is that this study
shows that patents on Medicaid do not do much better than uninsured
patients. What can we make of this?

Medicaid coverage is limited to low-income populations. These people
have many other problems that can result in impaired access and impaired
outcomes - conceivably enough to explain these differences. However,
Medicaid also may result in impaired access because of a lack of an
adequate number of physicians who are willing to care for Medicaid
patients. This is particularly true of specialists, such as oncologists
who would otherwise care for these patients with the most deadly
cancers. Impaired access due to a lack of willing providers applies to
both uninsured and Medicaid patients. That is not true for either
privately insured or Medicare patients.

Under a well designed single payer system - an improved Medicare for all
- physicians would not cull patients out of their practices merely
because they were on Medicaid or uninsured. Enacting single payer would
allow us to remove barriers based simply on the type of insurance
coverage or lack thereof. That would then allow us address other
important societal issues that result in impaired access, delayed or
forgone management, and impaired survival.

Although this study will be used by opponents as an excuse not to fund
Medicaid based on the fact that Medicaid patients did not do much better
than the uninsured, we cannot allow them to discount the other factors
faced by low-income patients that undoubtedly played a greater role in
these disparate outcomes. Many other studies have shown that Medicaid
patients definitely fare better than the uninsured. Until we can enact
and implement a single payer system, it is imperative that Medicaid
continue to be offered as an interim measure.