Effects of being uninsured or underinsured and living in extremely poor neighborhoods on colon cancer care and survival in California: historical cohort analysis, 1996—2011

Abstract

BackgroundWe examined the mediating effects of health insurance on poverty-colon cancer care and survival relationships and the moderating effects of poverty on health insurance-colon cancer care and survival relationships among women and men in California.MethodsWe analyzed registry data for 3,291 women and 3,009 men diagnosed with colon cancer between 1996 and 2000 and followed until 2011 on lymph node investigation, stage at diagnosis, surgery, chemotherapy, wait times and survival. We obtained socioeconomic data for individual residences from the 2000 census to categorize the following neighborhoods: high poverty (30% or more poor), middle poverty (5-29% poor) and low poverty (less than 5% poor). Primary health insurers were Medicaid, Medicare, private or none.ResultsEvidence of mediation was observed for women, but not for men. For women, the apparent effect of poverty disappeared in the presence of payer, and the effects of all forms of health insurance seemed strengthened. All were advantaged on 6-year survival compared to the uninsured: Medicaid (RR = 1.83), Medicare (RR = 1.92) and private (RR = 1.83). Evidence of moderation was also only observed for women. The effects of all forms of health insurance were stronger for women in low poverty neighborhoods: Medicaid (RR = 2.90), Medicare (RR = 2.91) and private (RR = 2.60). For men, only main effects of poverty and payers were observed, the advantaging effect of private insurance being largest. Across colon cancer care processes, Medicare seemed most instrumental for women, private payers for men.ConclusionsHealth insurance substantially mediates the quality of colon cancer care and poverty seems to make the effects of being uninsured or underinsured even worse, especially among women in the United States. These findings are consistent with the theory that more facilitative social and economic capital is available in more affluent neighborhoods, where women with colon cancer may be better able to absorb the indirect and direct, but uncovered, costs of care.

Better Colon Cancer Care for Extremely Poor Canadian Women Compared with American Women

“…Second, in the United States, people with private HI or Medicare coverage are more likely to receive the best, evidencebased care and to survive longer than are those with arguably less adequate Medicaid coverage or no coverage (Boland et al, 2013;Bradley, Given, Dahman, & Fitzgerald, 2008). Third, being poor, uninsured or Medicaid insured are all much more common among women than men in the United States (Gorey et al, 2012;DeNavas-Walt et al, 2012;Iceland, 2013). And fourth, HI has recently been found to substantially buffer the disadvantaging effects of poverty on colon cancer treatment and survival among women, but not men, in California (Gorey et al, 2012).…”

“…Third, being poor, uninsured or Medicaid insured are all much more common among women than men in the United States (Gorey et al, 2012;DeNavas-Walt et al, 2012;Iceland, 2013). And fourth, HI has recently been found to substantially buffer the disadvantaging effects of poverty on colon cancer treatment and survival among women, but not men, in California (Gorey et al, 2012). Colon cancer care seems quite sensitive to the sorts of social policy forces that probably determine much of the income and HI inequities, particularly among women, in North America.…”

“…This study was reviewed and cleared by the University of Windsor research ethics board. Other methodological details have been reported (Gorey, Luginaah, Bartfay, Fung, Holowaty, Wright, Hamm, & Kanjeekal, 2011, Gorey, Luginaah, Bartfay, Fung, Holowaty, Wright, Hamm, Kanjeekal, & Balagurusamy, 2011, Gorey et al, 2012.…”

“…Places of prevalent vulnerability, they are particularly distressed as a result of their lack of social and economic capital (Jargowsky, 2005;Kawachi, 1999;Wilson, 2012). Adequate health insurance (HI) is also commonly lacking among those who live in the poorest of America's neighborhoods, especially those who may need it the most, such as those with illnesses like colon cancer that can require very costly care (Gorey et al, 2012;Shankaran, Jolly, Blough, & Ramsey, 2012). Less is known about high-poverty neighborhoods in Canada, not surprisingly, as they are less prevalent and seem to be less deeply poor places than in the United States (Chen, Myles, & doi: 10.1093/hsw/hlt022 © 2013 National Association of Social Workers Picot, 2012).…”

Predictors and Mediators of Long-term Functional Limitations in the Older Adult Population

“…Another study found that Medicaid acts as a suppressor of racial disparities in health for children with special needs (Rose et al 2010). Gorey et al (2012) investigated the relationship between poverty, health insurance coverage, and quality of care received in patients with colon cancer. They reported that insurance mediates the quality of cancer care received and that living in poor neighborhoods moderates this effect.…”