Study Compares Survival for Cancer, Based on Health Insurance Status

A study published Thursday in JAMA Oncology found that improvements in survival among California cancer patients were almost exclusively limited to patients with private or Medicare insurance. Survival for patients with other public or no insurance was largely unchanged, or declined. The size of these disparities, specifically for patients with prostate, lung or colorectal cancer, may actually be growing over time.

The findings come even though Medicaid insurers have made substantial profits in California, relative to their peers in other states. Known as MediCal, the program insures more than 1 in 3 Californians, or 12.5 million people. Medicaid insurers in the Golden State have earned more off the program than Medicaid insurers in 34 other states combined that have managed care plans, earning $5.4 billion from 2014-2016. This was partially because the state paid higher rates in the first years of the implementation of the Affordable Care Act (ACA).

In comparison, before the ACA, California’s Medicaid plans were barely in the black, with $226 million of net income for 2012-2013 combined, with a slim profit margin of 2%-3%. Since the law has taken effect, many health insurers have posted margins 2-3 times that benchmark.

“Medicaid in California (MediCal) is neither safe nor effective. If MediCal were a drug, a responsible regulator should consider pulling it from the market. [this study] demonstrates that MediCal is a disaster for Californians,” said Stanford oncologist, Douglas Blayney, MD, in a statement.

The new study was compiled using data from the California Cancer Registry (a statewide cancer surveillance system) to estimate population-based survival by health insurance status in 3 calendar periods from 1997-2014. The study looked at patient data ranging from January 1997- December 2002, January 2003- December 2008, and January 2009- December 2014. Overall, 1,149,891 patients diagnosed with breast, colorectal, prostate, lung cancer, or melanoma in California were included in the study.

When compared to privately insured patients, cancer-specific mortality was higher in uninsured patients for all cancers except prostate, and disparities were largest from 2009 to 2014 for breast (HR, 1.72; 95% CI, 1.45-2.03), lung (men: HR, 1.18; 95% CI, 1.06-1.31 and women: HR, 1.32; 95% CI, 1.15-1.50), and colorectal cancer (women: HR, 1.30; 95% CI, 1.05-1.62). Mortality was also higher for patients with other public insurance for all cancers except lung, and disparities were largest from 2009 to 2014 for breast (HR, 1.25; 95% CI, 1.17-1.34), prostate (HR, 1.17; 95% CI, 1.04-1.31), and colorectal cancer (men: HR, 1.16; 95% CI, 1.08-1.23 and women: HR, 1.11; 95% CI, 1.03-1.20).

“A lack of access to preventative health care is likely to have played a key role in these survival disparities, especially for breast and colorectal cancer, for which established screening practices exist,” said the lead researcher of the study, Libby Ellis, PhD, in a statement.

The authors of the study concluded that in order to address these disparities in cancer survival, patients need access to health insurance that covers all the necessary elements of health care from prevention and early detection, through to timely treatment as well as long-term follow up.

A May 2017 study published in Cancer looked at 2 samples of Medicare beneficiaries aged 70 or older and determined whether they had received the recommended cancer screening based on the date of their recent preventive mammography or colonoscopy. The researchers stated that the ACA’s provision in eliminating out-of-pocket costs to patients for preventative services was intended to expand access to screen and reduce disparities.

“The findings support the removal of out-of-pocket expenditures as a barrier to the receipt of recommended preventive services but emphasize that for colonoscopy, other factors such as fear of sedation, perceived discomfort, and a need for bowel preparation should be considered,” researchers concluded.

Reference

Ellis L, Canchola AJ, Spiegel D. Trends in cancer survival by health insurance status in California form 1997 to 2014 [published online November 30, 2017]. JAMA Oncol. 2017; doi:10.1001/jamaoncol.2017.3846