Health Insurance Status Predicts Outcomes in Cancer Patients

Roxanne Nelson

July 03, 2014

Health insurance status appears to be an independent predictor of outcome in cancer patients in the United States. New data show that uninsured young adults who are uninsured are more likely to present with metastatic disease, be undertreated, and die after their diagnosis than their insured counterparts.

But insurance premiums might be beyond the reach of a subset of this population, according to a study published in the July 1 issue of the Journal of Clinical Oncology.

Although it is likely that the Patient Protection and Affordable Care Act (ACA) will improve insurance coverage for most young adults, some face prohibitive increases in their premiums, say lead researcher Ayal Aizer, MD, a radiation oncologist from the Harvard Radiation Oncology Program in Boston, and colleagues.

It is projected that premiums for men 21 to 29 years of age will rise by 56%, and that premiums for men 30 to 39 years of age will rise 49%. This could increase the likelihood of a person opting out of insurance coverage and subsequently facing a poor outcome after a cancer diagnosis, the researchers note.

"Oncologists should be aware of the poorer outcomes that uninsured patients with cancer display, even if they are diagnosed with an early curable form of cancer," Dr. Aizer told Medscape Medical News.

"Many of these patients do not end up getting the treatments they need, and even when they do, they appear to display poorer survival than patients who are insured," he explained.

Additional measures might need to be taken when physicians consult with uninsured patients, such as involving social workers, to ensure that patients can be treated appropriately, he said. "Many physicians already do advocate for uninsured and underinsured patients. We feel that physician advocacy can help patients receive the care that they need."

"Our study suggests that every effort should be made to improve insurance access nationally," Dr. Aizer added. "Motivated physicians should encourage young adults to sign up for insurance plans rather than pay a penalty, given the tangible benefits associated with insurance status identified in our study."

Insured Have Better Care, Outcomes

Dr. Aizer and colleagues looked at the effect of insurance status on cancer-specific outcomes in young adults.

They identified 39,447 patients 20 to 40 years of age who were diagnosed with cancer from 2007 to 2009 in the Surveillance, Epidemiology, and End Results (SEER) database. In this cohort, they evaluated the association between insurance status and stage at presentation, use of definitive therapy, and all-cause mortality.

Uninsured patients were more likely than insured patients to be male, younger, not white, not married, and from regions of lower income, education, and population density (P < .001 for all).

The likelihood of presentation with metastatic disease, after adjustment for pertinent confounding variables, was significantly lower in insured than in uninsured patients (11.3% vs 18.5%; odds ratio [OR], 0.56; P < .001).

In addition, having health insurance was associated with the receipt of definitive treatment (OR, 1.95; P < .001) and a decreased rate of death from any cause (OR, 77; P = .002).

The was no difference in the effect of insurance status on all-cause mortality between men and women (P = .91 for interaction). However, the association between insurance status and definitive treatment was significantly stronger in women than in men (P = .02 interaction).

Policy Needs to Be Reconsidered

This study confirms results from previous studies on the effects of being uninsured, according to an accompanying editorial.

The study also touches on concerns about the high cost of insurance that is being reported in many states for men who are not covered by employer-sponsored insurance and who are not receiving subsidies, writes Gail Wilensky, PhD, senior fellow at Project HOPE, an international health education foundation based in Bethesda, Maryland.

 
It indicates the need to reconsider current policies.
 

Dr. Wilensky points out that one reason for the high cost of insurance for young adults, which is not mentioned by Dr. Aizer and colleagues, "is the result of a deliberate policy decision to assist older purchasers using a budget-neutral strategy. To the extent that their concern is regarded as a serious one, it indicates the need to reconsider current policies."

"The most direct cause of the high cost of insurance in this population is the policy decision to limit the variation in insurance premiums to 3 to 1, even though the differential in premium costs that is justified in actuarial terms is 5 to 1," she writes. "This was done to limit the cost that older, pre-Medicare purchasers face but it means that young purchasers, who have shown more reluctance to purchase insurance even when it is made available to them on a subsidized basis, face higher premiums than they would otherwise," she explains.

Dr. Wilensky notes that the "wisdom and equity" of this policy needs to be reconsidered.

Assessing the value of deliberate policy decisions is relatively straightforward, as it is for many aspects of public policy, she writes. "What is frequently harder — in this case, the increased challenge of getting already reluctant younger people to enroll — is assessing the unintended consequences likely to result and weighing the trade-off between the desired and the unintended consequences. It may be time to consider the latter."

The study was supported by a Heritage Medical Research Institute/Prostate Cancer Foundation Young Investigator Award, a Joint Center for Radiation Therapy Foundation grant, Fitz's Cancer Warriors, David and Cynthia Chapin, and a grant from an anonymous family foundation. Some of the coauthors report financial relationships with industry, as detailed in the publication.

J Clin Oncol. 2014;32: 1994-1995, 2025-2030. Editorial, Abstract

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