health coverage | Highlight HEALTH

With all the recent discussion and debate by the presidential candidates regarding healthcare issues, I thought a study published last month in CA: A Cancer Journal for Clinicians was quite timely. The study, titled Association of Insurance with Cancer Care Utilization and Outcomes, presents evidence that lack of adequate health insurance coverage is associated with reduced access to care and poorer outcomes for cancer patients [1]. The article further presents data on the association between health insurance status and screening, stage at diagnosis and survival for breast and colorectal cancer.

American Cancer Society (ACS) researchers analyzed over half-a-million patient cases using data from the National Cancer Data Base as well as data from the 2005 and 2006 National Health Interview Survey conducted by the National Center for Health Statistics and the Centers for Disease Control and Prevention (CDC). Perhaps not surprisingly, the results show that uninsured individuals are (1) less likely to receive cancer screening, (2) more likely to be diagnosed at an advanced disease stage and (3) less likely to survive than privately insured individuals.

National health survey and healthcare

People who are uninsured or insured by government programs may face significant obstacles obtaining healthcare. Indeed, some physicians do not accept new patients without private insurance or uninsured individuals who are not able to pay the full cost at the time of visit. A recent national survey found that while 96% of office-based physicians were currently accepting new patients, 40.3% indicated they would not accept new charity cases, 25.5% did not accept new Medicaid cases and 13.9% did not accept new Medicare cases [2]. This lack of access to healthcare can have adverse affects on preventive care and management for chronic conditions.

In the present ACS study, analyses of the 2006 National Health Interview Survey showed that 53.6% of uninsured people aged 18 to 64 years had no usual source of healthcare compared to just 9.9% of privately insured and 10.8% of individuals with Medicaid insurance. People who are uninsured were much more likely to report no healthcare visits in the past year than people who are privately- or Medicaid-insured. Compared to insured individuals, people who were uninsured were more likely to report that they did not get care due to cost, delayed care due to cost, did not get prescription drugs due to cost and had no healthcare visits in the past 12 months due to cost.

National health survey and cancer prevention

Up to two-thirds of cancers may be prevented through healthy lifestyle changes. Healthcare visits provide an opportunity for health providers to counsel people on smoking cessation and weight loss. However, uninsured individuals are much more likely to report no healthcare visits in the past 12 months than people who are Medicaid- or privately-insured and are thus much less likely to be advised to quit smoking or to lose weight. Further, analyses of the 2006 National Health Interview Survey showed that the likelihood of receiving recommended cancer screening tests varied by insurance status. Privately-insured women were most likely to have had a mammogram or Pap test, followed by Medicaid-insured women. Similarly, privately-insured men were most likely to have had a test for prostate cancer, followed by Medicaid-insured men. Further, both men and women who were privately insured were most likely to have had a colorectal cancer screening test. In all cases, uninsured individuals were least likely to have had any type of cancer screening.

Health insurance status is associated with other sociodemographic characteristics (e.g. race, level of education). However, when the data was analyzed by race, at every level of education, individuals with health insurance were about twice as likely as those without to have had mammography or colorectal cancer screening. Thus, having health insurance is an important predictor of cancer screening.

Insurance status, cancer stage at diagnosis and survival

ACS researchers also analyzed data from the National Cancer Data Base to investigate the relationship between insurance status, cancer stage at diagnosis and survival. In analyses of cancer survival for all cancers, uninsured individuals and Medicaid-insured individuals were 1.6 times more likely to die in 5 years than those with private insurance. Specifically, 35% of uninsured patients died in five years compared with 23% of privately insured patients. Since cancer screening tests are key to diagnosing and treating cancer in its early stages, not surprisingly people with health insurance were more likely to be diagnosed with early stage disease than individuals without insurance.

These results are consistent with previous studies showing that people who are uninsured or have Medicaid insurance are more likely to be diagnosed with late-stage cancer (breast and cancer of the mouth or throat, respectively) than people who are privately insured [3-4].

According to Dr. Otis Brawley, chief medical officer of the American Cancer Society [5]:

This report clearly suggests that insurance and cost-related barriers to care are critical to address if we want to ensure that all Americans are able to share in the progress we have achieved by having access to high-quality cancer prevention, early detection, and treatment services.

Research has shown that healthy lifestyle changes can prevent cancer. Additionally, advances in cancer detection and treatment have resulted in a decline in US cancer deaths in 2003 and 2004, the first decrease seen since 1930.

The American Cancer Society launched the Access to Care campaign in 2007. Access to Care is a national initiative dedicated to raising awareness about the predicament of uninsured and underinsured people in the United States. The campaign encourages Americans to find ways to fix the problem and make access to healthcare a national priority.

What are your thoughts? How can we reasonably and responsibly make healthcare accessible to everyone?

References

Ward et al. Association of insurance with cancer care utilization and outcomes. CA Cancer J Clin. 2008 Jan-Feb;58(1):9-31. Epub 2007 Dec 20.
View abstract
Hing and Burt. Characteristics of office-based physicians and their practices: United States, 2003–04. Series 13, No. 164. Hyattsville, MD: National Center for Health Statistics. 2007.
Halpern et al. Insurance status and stage of cancer at diagnosis among women with breast cancer. Cancer. 2007 Jul 15;110(2):403-11.
View abstract
Chen et al. The impact of health insurance status on stage at diagnosis of oropharyngeal cancer. Cancer. 2007 Jul 15;110(2):395-402.
View abstract
Report Links Health Insurance Status With Cancer Care. American Cancer Society News Center. 2007 Dec 20.

$60 billion dollars in new deficit spending.

That’s the amount the Heritage Foundation, a public policy research institute based in Washington D.C., estimates the Senate bill to reauthorize the State Children’s Health Insurance Program (SCHIP) will have added to the U.S. budget deficit over the next decade [1-2]. Under the bill, funding will drop sharply in 2013 (see the graph below). Assuming a 6% annual spending increase will be required to maintain current enrollment from 2012-2017, the program will require $84.3 billion rather than the $25.6 billion included in the bill.

The House bill has an even greater cost. According to the Congressional Budget Office (CBO) and the Joint Committee on Taxation (JCT), the U.S. House of of Representatives SCHIP bill would add $72.9 billion dollars to the U.S. budget deficit for the 2008-2017 period [3].

Previously, I wrote about the funding debate lawmakers were having over the State Children’s Health Insurance Program (SCHIP). Legislation was approved by the U.S. House of Representatives last week with a bill, the Children’s Health and Medicare Protection Act of 2007, to expand SCHIP funding to $50 billion over the next five years and to more than double the number of children that will be covered. The bill had bipartisan governor backing as well as the backing of a number of well-known organizations, including the American Medical Association (AMA), the AARP, the March of Dimes, the Catholic Health Association and the American Academy of Pediatrics.

The U.S. Senate followed a day later, approving their own legislation for a $35 billion dollar expansion of the program. The vote majority is more than enough to overcome the veto threatened by the adminstration.

According to the Center on Budget and Policy Priorities, the House bill differs from the Senate bill in that [4]:

” … it does not limit the existing SCHIP coverage of low-income parents of children who are enrolled in SCHIP or Medicaid, and thus does not lead to some children losing coverage as a consequence. (Various studies have found that jointly covering children and their parents results in a larger share of the eligible children signing up and receiving health care services. In response to a question posed last week during the Senate Finance Committee’s consideration of the SCHIP legislation, [Congressional Budget Office] CBO director Peter Orszag explained that ‘restricting eligibility to parents does have an effect on take up among children … for every 3 or 4 parents you lose, you might lose 1 or 2 kids, for example.’)”

SCHIP does more than insure low-income children - in many cases it provides insurance for their parents too. Why? Because parents are more likely to sign their children up for SCHIP if they can be covered as well. Indeed, today the program covers more than 600,000 adults and, in three states, actually covers more adults than children [5].

SCHIP was originally designed to provide health coverage for uninsured children in low-income families that earn no more than twice the federal poverty limit (approximately $34,000 a year for a family of three). The program provides federal matching funds to states with a cap on total federal expenditures of $40 billion over 10 years. The legislation Congress has passed will expand SCHIP eligibility to families that earn up to four times the federal poverty limit. This means a family of four earning $80,000 a year would be eligible for the program.

Both the Senate and House bill propose to fund an expanded SCHIP program with increased federal tobacco taxes, citing studies that have found that increasing cigarette prices reduces cigarette smoking among both adults and adolescents [6-7].

Does it make any sense to fund a healthcare program that will most assuredly have increasing costs every year from an income source with decreasing revenues?

That is, unless we can increase the tax base by getting 22 million more people to smoke.

Funding a healthcare program with a tobacco tax will not work. Those people using tobacco products will likely depend upon the healthcare system for one reason or another, including cancers, respiratory diseases and/or cardiovascular diseases. Eventually, we all pay for smoking-related illnesses with increased medical costs and health insurance premiums.

The Heritage Foundation cites several of these points with regard to the proposed SCHIP funding [8]:

While a tobacco tax is a politically popular funding source, it has several significant shortcomings:

A tobacco tax disproportionately burdens low-income Americans, lacks long-term stability, and ultimately results in significant shifting of health care costs onto others.

With the number of smokers already declining, a tobacco tax would further reduce the number of smokers, thereby eroding the funding source.

To produce the revenues that Congress needs to fund SCHIP expansion through such a tax would require 22.4 million new smokers by 2017.

Rather than making SCHIP dependent on increasing the number of smokers, Congress should refrain from narrow government program expansions and work on a broader strategy for improving access to affordable, private health insurance for all Americans - including children.

I’ve written in the past about Healthcare Costs and the Looming U.S. Budget Crisis. The U.S. is headed for the most significant budget crisis in history unless it reforms healthcare spending. Government Accountability Office (GAO) projections show that by as early as 2024, Social Security, Medicare, Medicaid and net interest will consume all federal revenues; by 2037 the federal government deficit will reach 20.5% of gross domestic product (GDP), exceeding the size of today’s federal budget [9].

What does that mean to you?

The nation’s top accountant, U.S. Comptroller General David Walker, warns that if nothing changes, by 2040 the federal government won’t have money left to pay for anything other than interest and some entitlement benefits. No money - zero, zilch, nada - for anything else, including national defense and homeland security.

Now ask yourself, with this clear and present financial disaster before us, why has Congress passed bills that will further increase the U.S. budget deficit?

Don’t misunderstand me. I think SCHIP is important and should be expanded to cover more children from low-income families, as long as we can find a way to responsibly fund the program.