Effect of Insurance Status on the Stage of Breast and Colorectal Cancers in a Safety-Net Hospital

The impact of race and ethnicity is summarized in Table 3. Black patients were more likely than Hispanic patients to be uninsured and more likely to have advanced-stage disease. White patients had a high rate of advanced disease, but because there were only 15 white patients, this was not significant. The relationships between race and ethnicity and both insurance status and advanced disease were highly significant. Because there were few patients in the white, other, and unknown groups, the effect of race and ethnicity on both insurance status and advanced disease was re-examined between blacks and Hispanics only. In this subgroup, the association between black patients and advanced-stage disease was significant (P = .021), whereas the association between black patients and lack of insurance only approached significance (P = .099).

In multivariate logistic regression, independent predictors of advanced disease were location of tumor (colorectal vs breast; P = .001), race (black vs Hispanic; P = .032), and insurance status (uninsured vs insured; P = .002). Age and sex were not predictive of advanced disease.

Discussion

Almost 50 million people in the United States do not have medical insurance.²² This has an impact on many medical problems^23-25 and is a major barrier to preventive care.^26,27 In particular, not being insured represents a major barrier to screening programs for cancer.^3,6-8,28 Presumably as a result of this, several large studies have demonstrated that patients without insurance present with more advanced stages of cancer.^9-15

This widespread lack of insurance was a major issue in the recent healthcare debates in this country. A major part of the new healthcare law—PPACA—was to increase access to health insurance for more Americans. It is estimated that 32 million Americans will gain access to health insurance as a result of this law.²⁹ According to the Centers for Medicare & Medicaid Services, the majority of these newly insured patients will be in the Medicaid program, with 20 million new enrollees expected by 2019.¹⁶

Many studies have shown that patients insured with Medicaid often have healthcare outcomes similar to those of patients without insurance.^{10,12-15,30,31} In a large study investigating the association between payer status and cancer stage in 12 cancer sites, both uninsured and Medicaid patients had increased rates of advanced disease.⁹ In many of the sites, Medicaid patients had higher rates than those without insurance at all.

Patients insured through Medicaid often have difficulty gaining adequate access to care.³² Many physicians do not accept Medicaid-insured patients in their practice, and many neighborhoods do not have adequate numbers of clinics or practices accepting Medicaid.

Our hospital is based in an inner-city setting, and a large majority of our patients are insured through Medicaid. There are few privately practicing physicians in the hospital system; the vast majority are employed by the hospital. As such, all physicians in our hospital system see Medicaid patients, and many of the barriers to care have been removed. Hospitals such as this have been termed safety-net hospitals.^18-21 The data from this study show that in terms of stage of cancer at diagnosis, patients in our hospital insured through Medicaid are similar to patients with other kinds of insurance. Even patients with commercial insurance had no advantage over Medicaid patients. We feel that this is the result of Medicaid patients having equal access to care in our safety-net hospital.

In the setting of the new PPACA law, this has important significance. Although many new patients will acquire health insurance, a majority of these patients will be enrolled in Medicaid.^16,33,34 Medicaid patients in other settings have tended to present with later stages of cancer; however, if they seek care in safety-net hospitals, it is possible that they can expect to have results similar to those of other insured patients.

With regard to uninsured patients, our results confirm the findings seen in other studies: patients without insurance presented with more advanced stages of cancer. In addition to being set up to treat Medicaid patients, our hospital also has mechanisms in place for uninsured patients. We have an extensive charity care program, and uninsured patients are able to obtain mammograms and colonoscopies. Nonetheless, they presented with later stages of disease. It is possible that the added hassle of having to apply for charity care was a barrier to care. It is also possible that uninsured patients are seeing fewer healthcare providers outside of the hospital setting and are not receiving the same amount of screening. Furthermore, many uninsured patients are unaware of the safety-net programs available to them.³⁵

One of the limitations of this study is that it was a singleinstitution study. However, although it may not translate to every hospital setting, we feel that in contrast to national database studies, this study provides a clearer picture of cancer care in safety-net hospitals. In addition, we were able to review each medical record individually. This allowed us to more accurately identify the true insurance status of each patient, especially with regard to uninsured patients receiving emergency Medicaid coverage. These patients, who received coverage only after their diagnosis (even if it was retroactive to the date of diagnosis), have been shown to present with more advanced stages of cancer.³⁶ Another weakness is that there were few white patients; almost the entire patient population was either black or Hispanic. However, perhaps this too is more representative of safety-net hospitals.

Finally, we did not look at whether our individual patients were screened. We relied on well-established and previously published data showing that uninsured patients are screened less frequently. However, a future study could look specifically at the rates of screening in different groups of patients. This would let us determine whether the higher rates of advancedstage disease seen in the uninsured patients in this study were actually a result of less screening or not.

Another potential study, which might be easier to conduct after the start of the new healthcare law, would be to determine whether providing health insurance for previously uninsured patients affects their rates of screening and/or of advanced disease. Is it really their insurance status that is the deciding factor of their cancer presentations, or are there other related factors?