Health Insurance Coverage Disruptions and Cancer Care and Outcomes: Systematic Review of Published Research

Abstract

<jats:title>Abstract</jats:title> <jats:sec> <jats:title>Background</jats:title> <jats:p>Lack of health insurance coverage is associated with poor access and receipt of cancer care and survival in the United States. Disruptions in coverage are common among low-income populations, but little is known about associations of disruptions with cancer care, including prevention, screening, and treatment, as well as outcomes of stage at diagnosis and survival.</jats:p> </jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>We conducted a systematic review of studies of health insurance coverage disruptions and cancer care and outcomes published between 1980 and 2019. We used the PubMed, EMBASE, Scopus, and CINAHL databases and identified 29 observational studies. Study characteristics and key findings were abstracted and synthesized qualitatively.</jats:p> </jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>Studies evaluated associations between coverage disruptions and prevention or screening (31.0%), treatment (13.8%), end-of-life care (10.3%), stage at diagnosis (44.8%), and survival (20.7%). Coverage disruptions ranged from 4.3% to 32.8% of patients age-eligible for breast, cervical, or colorectal cancer screening. Between 22.1% and 59.5% of patients with Medicaid gained coverage only at or after cancer diagnosis. Coverage disruptions were consistently statistically significantly associated with lower receipt of prevention, screening, and treatment. Among patients with cancer, those with Medicaid disruptions were statistically significantly more likely to have advanced stage (odds ratios = 1.2-3.8) and worse survival (hazard ratios = 1.28-2.43) than patients without disruptions.</jats:p> </jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Health insurance coverage disruptions are common and adversely associated with receipt of cancer care and survival. Improved data infrastructure and quasi-experimental study designs will be important for evaluating the associations of federal and state policies on coverage disruptions and care and outcomes.</jats:p> </jats:sec>

Health Insurance Disruptions and Care Access and Affordability in the U.S.

“…12 Among patients with cancer, Medicaid coverage disruptions are associated with later-stage diagnosis and worse survival. 13 Previous studies of populations with Medicaid coverage used Medicaid enrollment and claims data 13−15 and could not distinguish between individuals who were previously uninsured and individuals with previous private coverage. Furthermore, previous studies did not separately evaluate the disruptions in private coverage, most of which is employer-sponsored and the most common type of health insurance coverage in the working-age population.…”

Patterns of overall mortality by race/ethnicity and socioeconomic status in insured cancer patients in Southern California

“…Many different factors contribute to these disparities including baseline socioeconomic (SES); distributions by race; access to screening and care; insurance status; tumor biology and characteristics; and differences in disease management and care delivery in various healthcare settings. Having health insurance is strongly associated with better overall survival as well as cancer-specific outcomes such as recurrence and progression-free survival [5][6][7][8][9][10][11][12][13]. Although several recent studies have examined cancer outcomes by both race/ethnicity and SES, they included both patients with and without health insurance, making it difficult to disentangle the effects of health insurance coverage from other SES factors.…”

Time for action: The Patient Protection and Affordable Care Act Medicaid expansion significantly improves breast cancer care for women in Louisiana

“…Although disparities in breast cancer deaths are measured in numbers, their impact is felt in the women who have lost their lives. A strong predictor of breast cancer death is a lack of health insurance coverage and/or interruption of health care 20‐23 . Uninsured women are less likely to receive high‐quality breast cancer screening; once diagnosed with breast cancer, uninsured women are less likely to receive evidence‐based treatment 20 .…”

“…A strong predictor of breast cancer death is a lack of health insurance coverage and/or interruption of health care 20‐23 . Uninsured women are less likely to receive high‐quality breast cancer screening; once diagnosed with breast cancer, uninsured women are less likely to receive evidence‐based treatment 20 . A recent systemic review of health insurance coverage disruptions from 1980 to 2019 demonstrated that coverage disruptions were statistically associated with lower prevention and cancer screening, and patients with Medicaid disruptions (vs those without disruptions) were more likely to have advanced stage cancer (odds ratio, 1.2‐3.8) and worse survival (hazard ratio, 1.28‐2.43) 20 .…”

“…Uninsured women are less likely to receive high‐quality breast cancer screening; once diagnosed with breast cancer, uninsured women are less likely to receive evidence‐based treatment 20 . A recent systemic review of health insurance coverage disruptions from 1980 to 2019 demonstrated that coverage disruptions were statistically associated with lower prevention and cancer screening, and patients with Medicaid disruptions (vs those without disruptions) were more likely to have advanced stage cancer (odds ratio, 1.2‐3.8) and worse survival (hazard ratio, 1.28‐2.43) 20 . This study demonstrates that interruption of heath care coverage, particularly Medicaid, adversely impacted both cancer care delivery and, ultimately, survival.…”