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Uninsured Americans are less likely to get screened for cancer, more likely to be diagnosed with an advanced stage of the disease, and less likely to survive that diagnosis than their privately insured counterparts, according to a new American Cancer Society report examining the impact of health insurance status on cancer treatment and survival.

The article, posted online today and set to be published in the January-February 2008 issue of CA: A Cancer Journal for Clinicians, the peer-reviewed journal of the American Cancer Society, was authored by American Cancer Society researchers, led by Elizabeth Ward, PhD, managing director, surveillance research.

Previous studies have shown that uninsured and Medicaid patients are more likely to be diagnosed with late-stage cancers, in large part because they can't afford preventive services and cancer screening. This report looks at the relationship between health insurance status and cancer care more closely, weighing demographic and socioeconomic factors as well as race.

"This report clearly suggests that insurance and cost-related barriers to care are critical to address if we want to ensure that all Americans are able to share in the progress we have achieved by having access to high-quality cancer prevention, early detection, and treatment services," said Otis Brawley, MD, chief medical officer of the American Cancer Society, when the report was released.

Many Forego Care

American Cancer Society researchers analyzed 598,635 cases using the most recent data from the National Cancer Data Base (NCDB), a hospital-based registry held by ACS and the Commission on Cancer of the American College of Surgeons. The NCDB tracks approximately 70% of the cancer cases in the United States and collects data from about 1,500 hospitals. The patients included had either private insurance, Medicaid, or no insurance. The researchers also examined data from the 2005 and 2006 National Health Interview Survey (NHIS), a nationwide in-person survey of approximately 40,000 U.S. households conducted by the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention (CDC).

For all cancers combined, the ACS researchers found that uninsured patients were 1.6 times as likely to die within 5 years compared to individuals with private insurance.

People with lower incomes were less likely to have insurance, the report found. And those without insurance were less likely to use certain health services. About 54% of uninsured patients aged 18 to 64 did not have a usual source of health care. About 26% delayed care due to cost, while nearly 23% did not get care because of cost. An estimated 23% did not get prescription drugs because of the expense.

"For too many hardworking 'average Americans' paying for cancer treatment means not paying rent, mortgage (resulting in foreclosure or eviction), or utility bills, or even going hungry," wrote Elmer Huerta, MD, American Cancer Society president, in an accompanying editorial.

Discouraging Numbers

In addition to analyzing data for causal relationships, ACS researchers focused on insurance status and cancer care among breast and colorectal cancer patients, two of the most commonly-occurring cancers in the United States (see "What Are the Key Statistics for Breast Cancer?" and "What Are the Key Statistics for Colorectal Cancer?"). Screening tests can often find these cancers early, and in many cases, effective treatments are available.

Individuals with health insurance were about twice as likely as those without to have had a recent mammogram or colorectal cancer screening. Uninsured women were about half as likely as privately-insured women to have received a mammogram in the past 2 years, a figure that was fairly consistent across all women studied, regardless of race or ethnicity. Only about 19% of uninsured adults aged 50 to 64 went in for a colorectal cancer screening test, compared to about 48% of those with private insurance. People with insurance were also more likely to be diagnosed with early stage disease and less likely to be diagnosed with advanced stage disease than the uninsured.

The researchers saw a survival difference in breast and colorectal cancer, too. About 89% of privately insured white women with breast cancer survived at least 5 years, compared to 76% of white women with Medicaid or no insurance. Among African-American women, 81% of breast cancer patients with private insurance survived 5 years, compared to 65% of those on Medicaid and 63% of those without insurance. A similar pattern emerged in colorectal cancer. Among white patients with private insurance, 66% survived 5 years, compared to 50% of those with no insurance and 46% of those on Medicaid. Among African Americans, 60% with private insurance survived 5 years compared to 41% of the uninsured and Medicaid patients.

Barriers to Care

The risk of being uninsured or underinsured varies.

Adults aged 18 to 24 have the highest probability of being uninsured, and African Americans, Hispanics, Asian American/Pacific Islanders, and American Indian/Alaska Natives are much more likely to be uninsured than non-Hispanic whites.

"It's important to note that although variations in health insurance coverage likely contribute to racial and ethnic disparities in cancer outcomes, those disparities persist for several outcomes even when differences in insurance status are accounted for," said ElizabethWard, PhD, the report's lead author. "So even if health insurance and financial barriers can be overcome, further research and interventions will be needed to address these other barriers."

Almost anyone can be underinsured in the event of a major illness. The underinsured, commonly defined as people who spend more than 10% of their after-tax household income on out-of-pocket expenses in the event of a serious illness, often don't realize the gravity of their situation until faced with high premiums and deductibles, limits on terms for covered services, and caps on monthly, lifetime, or disease-specific coverage.

According to a 2003 study sponsored by the Agency for Health Care Research and Quality, the prevalence of being underinsured increased from 6.7% to 8.5% among nonelderly adults between 1996 and 2003. These numbers shot up when the costs of health insurance premiums were factored in. Among people with cancer, 29% had out-of-pocket expenses that exceeded 10% of their family's income and about 11% exceeded it by 20%.

In 2007, the American Cancer Society launched the Access to Care campaign, a national initiative dedicated to raising awareness about the plight of uninsured and underinsured people in the United States. The campaign encourages Americans to get involved in finding ways to fix the problem and make access to care a national priority.

Citation: "Association of Insurance with Cancer Care Utilization and Outcomes." Published online Dec. 20, 2007, and in the Jan/Feb 2008 issue of CA: A Cancer Journal for Clinicians (Vol. 58, No.1). First author: Elizabeth Ward, PhD, American Cancer Society.