Mediation of the effects of living in extremely poor neighborhoods by health insurance: breast cancer care and survival in California, 1996 to 2011

Abstract

BackgroundWe examined the mediating effect of health insurance on poverty-breast cancer care and survival relationships and the moderating effect of poverty on health insurance-breast cancer care and survival relationships in California.MethodsRegistry data for 6,300 women with breast cancer diagnosed between 1996 and 2000 and followed until 2011 on stage at diagnosis, surgeries, adjuvant treatments and survival were analyzed. Socioeconomic data were obtained for residences from the 2000 census to categorize neighborhoods: high poverty (30% or more poor), middle poverty (5%-29% poor) and low poverty (less than 5% poor). Primary payers or health insurers were Medicaid, Medicare, private or uninsured.ResultsEvidence of survival mediation was observed for women with node negative breast cancer. The apparent effect of poverty disappeared in the presence of Medicare or private health insurance. Women who were so insured were advantaged on 8-year survival compared to the uninsured or those insured by Medicaid (OR = 1.89). Evidence of payer moderation by poverty was also observed for women with node negative breast cancer. The survival advantaging effect of Medicare or private insurance was stronger in low poverty (OR = 1.81) than it was in middle poverty (OR = 1.57) or in high poverty neighborhoods (OR = 1.16). This same pattern of mediated and moderated effects was also observed for early stage at diagnosis, shorter waits for adjuvant radiation therapy and for the receipt of sentinel lymph node biopsies. These findings are consistent with the theory that more facilitative social and economic capital is available in low poverty neighborhoods, where women with breast cancer may be better able to absorb the indirect and direct, but uncovered, costs of care. As for treatments, main protective effects as well as moderator effects indicative of protection, particularly in high poverty neighborhoods were observed for women with private health insurance.ConclusionsAmerica’s multi-tiered health insurance system mediates the quality of breast cancer care. The system is inequitable and unjust as it advantages the well insured and the well to do. Recent health care reforms ought to be enacted in ways that are consistent with their federal legislative intent, that high quality health care be truly available to all.

Determinants of treatment waiting times for head and neck cancer in the Netherlands and their relation to survival

“…This finding is concordant with earlier reports showing longer waiting times for patients with a lower SES, e.g. in breast cancer [28]. However, low SES was also associated with a higher stage (35% stage IV in low SES versus 32% stage IV in high SES) and were therefore treated with chemoradiation more frequently.…”

Sobrevida por câncer de mama e iniquidade em saúde

“…Studies in the United States have shown shorter survival time of women who use Medicaid (public health system for people under the poverty line), compared to those who have private health insurance 15,22 . Studies conducted in Brazil and other Latin American countries found a positive association between socioeconomic status of the patient and breast cancer survival 6,23,24 .…”

“…In addition to staging, a number of studies identified, as influencing factors of the relation between socioeconomic status and survival, the access to health services for screening, diagnosis and treatment, and, in a smaller proportion, the histologic type and grade, biomarkers such as hormone receptors, and the overall health status of the patient in relation to the presence of morbid conditions 16 . The social status of the area of residence is also identified, with its effect mediated mainly by the patient having or not having private health insurance 22 . In most studies carried out in the United States, socioeconomic status and race/skin color had independent effects in breast cancer survival 34 .…”

Breast Cancer among Women Living in Poverty: Better Care in Canada than in the United States

“…First, income has been observed to be strongly associated with breast cancer care and survival in the US, but not in Canada (Gillan et al, 2012;Gorey, 2009;McKenzie & Jeffreys, 2009). Second, in the US women with private HI or Medicare coverage are more likely to receive better care than are women with arguably less adequate coverage such as that provided through the Medicaid programs of many states or none (Coburn et al, 2008;Gorey et al, 2013;Schueler, Chu, & Smith-Bindman, 2008;Subramanian et al, 2011). And third, studies of breast cancer survival in Canada and the US have consistently observed better survival in Canada among the poor, but no systematic differences within middle or upper socioeconomic strata (Gorey, 2009).…”