Cancer care and survival are affected by common disruptions in health insurance coverage
A systematic review finds that health insurance disruptions are common and adversely affect cancer treatment and survival. Medicaid coverage disruptions were particularly impactful among patients with cancer, associated with advanced stage diagnosis, delays to testing and worse survival.
A study conducted by researchers across a range of institutions, led by K. Robin Yabroff (American Cancer Society, GA, USA), has reviewed 29 papers on the effects of disruptions to health insurance coverage on treatment, care and survival of patients with cancer in the USA.
While it has long been apparent that US citizens who do not have health insurance are likely to suffer worse outcomes from cancer diagnoses, the review published in the Journal of the National Cancer institute looks for the first time at the effects of disruptions to coverage across a range of observational studies. Disruptions can be caused by changes to insurance plans, gaps in coverage or changes in eligibility of patients.
The number of uninsured Americans has fallen dramatically since the implementation of the Affordable Care Act, particularly in states with expanded eligibility for Medicare. However, disruptions to insurance cover remain most common in poorer cohorts and recipients of Medicare, with loss of coverage for 1 month associated with worse access to care, delays in care, increased emergency department use and lowered overall health.
Our findings were consistent across multiple cancer sites, with several studies finding a ‘dose-response’ relationship, meaning the longer the disruption, the worse the care,"
– Robin Yabroff.
In the study, researchers observed that disruptions to insurance coverage were significantly associated with less frequent receipt of prevention and screening procedures. Unsurprisingly, disruptions were also associated with later stage diagnoses of a range of cancer types. Between 22.1% and 59.5% of patients enrolled in Medicaid did so at or after diagnosis, and the authors noted that one-time users of the Breast and Cervical Cancer Early Detection Program (who are automatically enrolled in Medicaid if they are diagnosed with cancer and are uninsured) were likely to be diagnosed at a later stage compared with patients enrolled in Medicaid before diagnosis.
Investigators also observed that coverage disruptions were associated with delays to treatment. Particularly, patients who enrolled in Medicaid at or after diagnosis with cancer faced significantly worse survival, although this was moderated if diagnosis was at an early stage – early-stage diagnosis being less likely for uninsured or disrupted insurance patients.
With changes to work requirements in some state Medicaid programs and the increased numbers of workers with fluctuating incomes (for example Uber and Lyft employees), there may be increased disruption to insurance coverage due to changes to eligibility. It was also noted that despite a high use of private healthcare insurance, no published literature was identified by the authors assessing the effect of private health insurance coverage disruptions on cancer care and outcomes.
So far, there is a lack of published literature on interventions to improve continuity of coverage, although the authors noted some ongoing work that might improve this; these include testing the use of electronic health records to avoid disruption to care during patients’ Medicaid recertification and incentive schemes for low-income patients to use high-quality cancer care providers.
Improvements to data infrastructure and ongoing studies will be important to assess and inform policy decisions. The study’s lead author, Robin Yabroff, concluded: "The consistency of these findings across the cancer control continuum in our review highlights how important it is to minimize breaks in health insurance coverage to address cancer disparities and promote health equity."
Yabroff KR, Reeder-Hayes K, Zhao J et al. Health insurance coverage disruptions and cancer care and outcomes: systematic review of published research. J Natl Cancer Inst. doi: 10.1093/jnci/djaa048 (2020) (Epub ahead of print); http://pressroom.cancer.org/Disruptions2020