At first blush, the numbers aren’t great: Cancer patients who are covered by Medicaid tend to have later-stage disease and higher rates of mortality.
But when Cathy Bradley, PhD, deputy director of the University of Colorado (CU) Cancer Center, started digging into the data a little deeper, she found some of the reasons for the dire statistics. Many people with cancer enroll in Medicaid only after they are diagnosed, suggesting they may have been uninsured prior to diagnosis and had limited access to cancer screening and treatment.
“What some researchers have done in the past is looked at Medicaid and observed that people who are insured by Medicaid and diagnosed with cancer have late-stage disease and greater mortality rates,” she says. “What I was able to show is that Medicaid is actually picking up people who were otherwise uninsured or underinsured. They get diagnosed with cancer, and enroll in Medicaid afterward. By then, they have late-stage cancer because they most likely did not have health insurance that would have given them access to screening and treatment prior to cancer diagnosis.”
In recent research published in the journal Cancer Epidemiology, Biomarkers & Prevention, Bradley also shows that cancer patients who were insured by Medicaid prior to diagnosis do about as well as people with private insurance.
“Ultimately, the message is that having continuous coverage in order to be able to get access to screening and care prevents late-stage disease and high mortality,” she says.
Insurance trumps income
Using data from the National Cancer Institute’s Surveillance, Epidemiology, and End Results Cancer Registry, linked with Medicaid enrollment data, Bradley looked at the association between Medicaid enrollment and distant stage for three screening-amenable cancers: breast, cervical, and colorectal. In addition to her general findings about the importance of continuous insurance coverage, she looked specifically at the National Breast and Cervical Cancer Early Detection Program, a Centers for Disease Control initiative that offers free breast and cervical cancer screening to uninsured or underinsured low-income women who were not low-income enough to qualify for Medicaid initially.
“If cancer is found, these women are enrolled in their state Medicaid program, but Medicaid may only cover their cancer-related treatment rather than full coverage,” Bradley says. “Providers may also be reimbursed at a lower rate than regular Medicaid. What I was able to show is the breast and cervical cancer screening program — which has saved thousands of lives — is inferior to having continuous insurance coverage. Because these women, even though they were slightly higher income, it wasn't the income that made a difference. It was the health insurance.”
Call for coverage
Not surprisingly, Bradley’s paper concludes with a call for more insurance options for those with lower incomes. The Affordable Care Act, which went into effect in 2014, expanded Medicaid eligibility, but many states opted not to expand, setting their income thresholds much lower than the federal guidelines allow.
“Medicaid has gotten an undeserved bad rap. I’m certain Medicaid would rather have patients prior to diagnosis or early stage and take care of them rather than spend a whole lot of money and have them die,” Bradley says. “Even though states that expanded Medicaid greatly reduced the number of uninsured people, there are still over 12 million uninsured people who do not qualify for Medicaid and still don’t have health insurance. And those are the ones most vulnerable to late-stage diagnosis.”
The HIV-cancer connection
An economist by training, Bradley has a longtime interest in insurance and Medicaid and how they affect those diagnosed with cancer. In “An ounce of prevention: Medicaid's role in reducing the burden of cancer in men with HIV,” a recent editorial in the journal Cancer, she explains how people living with HIV have a greater incident of some cancers. Thanks to new treatments, many of these people are expected to live long-term and will require treatment for cancer, she says, and because many of them are also insured by Medicaid, new approaches to public health practice and policy are needed.
“Cancer drugs can be super-expensive, and we've got to think about this complex care of providing for people with both conditions, when 20-30 years ago, you would have died from either of them,” she says. “Now both become chronic, and the cost of the drugs for both conditions is very expensive.”
To avoid these costs, she says, greater emphasis on prevention through HPV vaccination and screening is needed. Measures to control drug costs will also be needed as the population grows.