Uninsured U.S. cancer cases decline despite ‘alarming’ lack of coverage in some states
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Key takeaways:
- The uninsured rate among cancer cases dropped by more than half in Medicaid expansion states from 2010 to 2019.
- Less than 20% of new cancer cases in 2019 had Medicaid coverage at diagnosis.
The proportion of individuals with newly diagnosed cancer who lacked insurance in the U.S. declined significantly from 2010 to 2019, according to data published in Health Affairs Scholar.
Despite the increase in overall coverage, researchers found notable variations in insurance coverage among the states, especially among those that have yet to expand Medicaid eligibility after passage of the Affordable Care Act.
“Cancer care can be very expensive, especially given recent advancements in targeted therapy and immunotherapy,” Xin Hu, PhD, MSPH, assistant professor in the department of public health sciences at University of Virginia School of Medicine, told Healio.
“Not having health coverage could mean that the patient either forgoes life-saving treatments or the hospital would need to cover the costs through their charity program,” she added. “Lack of insurance may also result in delays in cancer screening and diagnoses at later stages, which could compromise clinical outcomes.”
Background and methodology
Health insurance coverage is a strong determinant of both cancer care access and survival within the United States, according to study investigators.
Hu and colleagues examined changes in primary insurance coverage for individuals with newly diagnosed cancer in the U.S. since the expansion of Medicaid income eligibility under the Affordable Care Act.
Researchers used the Cancer Incidence in North American database to gather information from 2010 to 2019. They identified 6,432,117 incident cancer cases with known insurance status diagnosed between the ages of 18 to 64 years culled from population-based registries in 49 of the 50 U.S. states.
Results
Among expansion states, researchers observed a significant increase in Medicaid coverage for cancer cases from 14.1% in 2010 to 19.9% in 2019 (P < .001), whereas the Medicaid coverage rate remained lower (range, 11.7-12.7) in nonexpansion states.
Additionally, the uninsured rate decreased from 4.9% in 2010 to 2.1% in 2019 in expansion states, while nonexpansion states saw the uninsured rate drop less significantly — from 9.5% in 2010 to 8.1% in 2019.
States that saw the largest increases in Medicaid coverage among incident cancer cases in 2014 included Oregon, New Mexico and Kentucky, while those same three states had the largest decrease in uninsured rate.
Researchers noted that in 2019, 111,393 cancer cases (16.9%) had Medicaid coverage at time of diagnosis (range, 7.6-37.9 across states) and that 48,357 (4.4%) remained uninsured (range, 0.5-13.2) at time of diagnosis.
“It was reassuring to see a substantial increase in Medicaid coverage in Medicaid expansion states after 2014,” Hu said.
“However, the high percentage of uninsured cancer cases at diagnosis in certain nonexpansion states, notably Texas, was alarming,” she added. “In 2019, 13.2% of cancer cases (6,890) in Texas were uninsured at diagnosis, which could have important consequences on prognosis and survival.”
Two other nonexpansion states — Florida (2788 cases) and Georgia (2137 cases) — completed the list of the states with the most uninsured cancer cases.
Researchers acknowledged multiple study limitations, including a lack of known insurance status for some cases. They also noted that some states allow uninsured patients to retroactively gain Medicaid coverage, so the number of patients with Medicaid coverage at the time of diagnosis may be higher than reported.
Next steps
Patients with cancer still face significant challenges in obtaining care access and continuity, according to the researchers, with state cancer prevention and control efforts needed to mitigate cancer care disparities among particularly vulnerable populations.
“Immediately following our current work, it is critical to continue monitoring the trend after the March 2023 unwinding of Medicaid coverage protection,” Hu told Healio.
“Previous studies suggest that patients with newly gained Medicaid upon cancer diagnosis still had inferior outcomes than those continuously insured,” she added. “Therefore, identifying potential gaps in Medicaid continuity patterns may inform future reforms, including providing free and accessible cancer screening and streamlining the Medicaid enrollment process upon cancer diagnosis.
“The Affordable Care Act is an important provision that expanded health care access to millions of people. While there is extensive evidence showing its positive implications, it cannot be emphasized enough that ongoing efforts are still needed to implement and sustain state-level Medicaid expansion and other cancer prevention and control programs. This continuous commitment is key to reducing disparities among vulnerable populations, including those with cancer.”
For more information:
Xin Hu, PhD, MSPH, can be reached at Department of Public Health Sciences, University of Virginia School of Medicine, 200 Jeanette Lancaster Way, Charlottesville, VA 22903; email: grg3dw@uvahealth.org.
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