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Introduction: Although the association between health insurance coverage and access to care is well documented, it is unclear whether the deleterious effects of being uninsured are strictly contemporaneous or whether previous disruptions in coverage have persistent effects. This study addresses this issue using nationally representative data covering 2011-2019 to estimate the extent to which disruptions in health insurance coverage continued to be associated with poor access even after coverage was regained., Methods: Analysis was conducted in 2022. Using a nationally representative cohort of insured adults aged 18-64 years (N=39,904) and multivariable logistic regression models, the authors estimated the association between past disruptions in coverage (occurring at least 1 year before) and the risks of lacking a usual source of care provider and having unmet medical need., Results: Among insured nonelderly adults, the risk of being without a usual source of care provider was between 18% (risk ratio=1.18; 95% CI=1.00, 1.38) and 75% higher (risk ratio=1.75; 95% CI=1.56, 1.93) than for those with continuous coverage; the risk of having unmet medical needs was between 41% (risk ratio=1.41; 95% CI=1.00, 1.83) and 66% (risk ratio=1.66; 95% CI=1.26, 2.06) higher. Longer insurance disruptions were associated with a higher risk of lacking a usual source of care provider., Conclusions: Previous disruptions in health insurance coverage continued to be negatively associated with access to care for more than a year after coverage was regained. Improving access to care in the U.S. may require investing in policies and programs that help to strengthen coverage continuity among individuals with insurance coverage rather than focusing exclusively on helping uninsured individuals to gain coverage., (Published by Elsevier Inc.)

Lay Summary: Cancer has substantial economic impacts for patients, their families and/or caregivers, employers, and the health care system. However, there is only limited understanding of how economic issues can affect access to cancer care services and the receipt of high-quality cancer care. Health economics research in cancer is particularly timely due to the large and increasing number of patients with cancer and cancer survivors, but there are many factors that may create barriers to performing cancer health economics research. This commentary has identified important topics and questions in cancer health economics research and will assist in the development of this critical field., (© 2020 American Cancer Society.)

Background: Lack of health insurance coverage is associated with poor access and receipt of cancer care and survival in the United States. Disruptions in coverage are common among low-income populations, but little is known about associations of disruptions with cancer care, including prevention, screening, and treatment, as well as outcomes of stage at diagnosis and survival., Methods: We conducted a systematic review of studies of health insurance coverage disruptions and cancer care and outcomes published between 1980 and 2019. We used the PubMed, EMBASE, Scopus, and CINAHL databases and identified 29 observational studies. Study characteristics and key findings were abstracted and synthesized qualitatively., Results: Studies evaluated associations between coverage disruptions and prevention or screening (31.0%), treatment (13.8%), end-of-life care (10.3%), stage at diagnosis (44.8%), and survival (20.7%). Coverage disruptions ranged from 4.3% to 32.8% of patients age-eligible for breast, cervical, or colorectal cancer screening. Between 22.1% and 59.5% of patients with Medicaid gained coverage only at or after cancer diagnosis. Coverage disruptions were consistently statistically significantly associated with lower receipt of prevention, screening, and treatment. Among patients with cancer, those with Medicaid disruptions were statistically significantly more likely to have advanced stage (odds ratios = 1.2-3.8) and worse survival (hazard ratios = 1.28-2.43) than patients without disruptions., Conclusions: Health insurance coverage disruptions are common and adversely associated with receipt of cancer care and survival. Improved data infrastructure and quasi-experimental study designs will be important for evaluating the associations of federal and state policies on coverage disruptions and care and outcomes., (Published by Oxford University Press 2020. This work is written by US Government employees and is in the public domain in the US.)

Lack of health insurance coverage is strongly associated with poor cancer outcomes in the United States. The uninsured are less likely to have access to timely and effective cancer prevention, screening, diagnosis, treatment, survivorship, and end-of-life care than their counterparts with health insurance coverage. On March 23, 2010, the Patient Protection and Affordable Care Act (ACA) was signed into law, representing the largest change to health care delivery in the United States since the introduction of the Medicare and Medicaid programs in 1965. The primary goals of the ACA are to improve health insurance coverage, the quality of care, and patient outcomes, and to maintain or lower costs by catalyzing changes in the health care delivery system. In this review, we describe the main components of the ACA, including health insurance expansions, coverage reforms, and delivery system reforms, provisions within these components, and their relevance to cancer screening and early detection, care, and outcomes. We then highlight selected, well-designed studies examining the effects of the ACA provisions on coverage, access to cancer care, and disparities throughout the cancer control continuum. Finally, we identify research gaps to inform evaluation of current and emerging health policies related to cancer outcomes., (© 2020 American Cancer Society.)

Introduction: In the U.S., rural residents have poorer health than urban residents and this disadvantage is growing. Therefore, it is important to understand rural-urban differences in access to medical care. This study compared the percentage of individuals with a usual source of care and characteristics of usual source of care providers across 3 urban-rural categories., Methods: This study identified 51,920 adults from the 2014-2016 Medical Expenditure Panel Survey and estimated the percentage with a usual source of care across the rural-urban categories. Then, differences in a variety of provider characteristics were examined. Estimates were weighted to be representative of the U.S. non-institutionalized population and adjusted for age, race/ethnicity, self-rated health, and presence of chronic conditions. Analysis was conducted in 2018 and 2019., Results: Compared with metropolitan county residents, residents of the most rural counties were 7 percentage points more likely to have a usual source of care (81% vs 74%), but their providers were 13 percentage points less likely to be physicians (22% vs 35%). Despite having to travel longer to reach their usual source of care providers, residents of the most rural counties were 18 percentage points less likely than metropolitan residents to have usual source of care providers with office hours on nights and weekends (27% vs 39%)., Conclusions: Rural-urban differences in access to care are complex; there is a rural disadvantage on some dimensions of access but not others. To understand rural-urban disparities in healthcare access, research should move beyond the usual source of care provider as an overall indicator and instead investigate disparities using multiple indicators of access based on theoretically distinct domains., (Published by Elsevier Inc.)

Purpose: To examine the associations among high-deductible health plan (HDHP) enrollment, cancer survivorship, and access to care and utilization., Materials and Methods: The 2010 to 2017 National Health Interview Survey was used to identify privately insured adults ages 18 to 64 years (cancer survivors, n = 4,321; individuals without a cancer history, n = 95,316). We used multivariable logistic regressions to evaluate the associations among HDHP/health savings account (HSA) status, delayed/forgone care for financial reasons, and hospital emergency department (ED) visits among cancer survivors compared with individuals without a cancer history., Results: Among cancer survivors, HDHPs with or without HSA (8.9% and 13.9%, respectively; both P < .05) were associated with more delayed/forgone care compared with low-deductible health plans (LDHPs) (7.9%). HSA enrollment was associated with less delayed/forgone care among HDHP cancer survivors ( P < .05). ED visits were similar by insurance type. Among individuals without a cancer history, HDHP with or without HSA (9.5% and 10.8%, respectively; both P < .05) were both associated with more delayed/forgone care compared with LDHPs (5.9%). HSA enrollment also was associated with less delayed/forgone care among HDHP enrollees without a cancer history. A small difference in ED visits was observed between HDHPs without HSA (15.3%) and LDHPs (14.1%; P < .05) or HDHPs with HSA (13.4%; P < .05) among individuals without a cancer history., Conclusion: HDHP enrollment and HSA status affect access to care and hospital ED visits similarly by cancer history. HDHP enrollment may serve as a barrier to access to care among cancer survivors, although HSA enrollment coupled with an HDHP may mitigate the impact on access. HDHPs and HSA status were not associated with ED visits among cancer survivors. Improvement to care coordination efforts may be needed to reduce ED visits among privately insured cancer survivors.

Between 1991 and 2015, the cancer mortality rate declined dramatically in the United States, reflecting improvements in cancer prevention, screening, treatment, and survivorship care. However, cancer outcomes in the United States vary substantially between populations defined by race/ethnicity, socioeconomic status, health insurance coverage, and geographic area of residence. Many potentially preventable cancer deaths occur in individuals who did not receive effective cancer prevention, screening, treatment, or survivorship care. At the same time, cancer care spending is large and growing, straining national, state, health insurance plans, and family budgets. Indeed, one of the most pressing issues in American medicine is how to ensure that all populations, in every community, derive the benefit from scientific research that has already been completed. Addressing these questions from the perspective of health care delivery is necessary to accelerate the decline in cancer mortality that began in the early 1990s. This article, part of the Cancer Control Blueprint series, describes challenges with the provision of care across the cancer control continuum in the United States. It also identifies goals for a high-performing health system that could reduce disparities and the burden of cancer by promoting the adoption of healthy lifestyles; access to a regular source of primary care; timely access to evidence-based care; patient-centeredness, including effective patient-provider communication; enhanced coordination and communication between providers, including primary care and specialty care providers; and affordability for patients, payers, and society., (© 2019 American Cancer Society.)

Little is known about the competing effects of increasing prescription drug costs and expansions in insurance coverage on prescription drug access and whether trends vary for adults with and without a cancer history. Using the 2010-2015 National Health Interview Survey, we examined trends in limited prescription drug access, operationalized as forgoing needed prescription drugs because of cost. The percentages of adults age 18 to 64 years with limited prescription drug access decreased over time: predicted margins from multivariable logistic regression models were 13.8% in 2010 vs 8.6% in 2015 for cancer survivors and 11.0% vs 6.8% for adults without a cancer history (adjusted odds ratio [aOR] for trend = 0.89, 95% confidence interval [CI] = 0.88 to 0.90). Access changed little for adults age 65 years and older. Among adults age 18 to 64 years, cancer survivors were more likely than those without a cancer history to report limited access to any prescription drug in all years (aOR from multivariable logistic regression model = 1.45, 95% CI = 1.31 to 1.61). However, trends did not differ by cancer history. Our findings suggest that expansions in health insurance coverage mitigated the effects of growing prescription drug costs to some extent for many individuals with and without a history of cancer., (Published by Oxford University Press 2017. This work is written by US Government employees and is in the public domain in the US.)

Objectives: Cancer survivors require appropriate health care to manage their unique health needs. This study describes access to cancer care among cancer survivors in the United States and compares access to general medical care between cancer survivors and people who have no history of cancer., Methods: We assessed access to general medical care using the core 2011 Medical Expenditure Panel Survey (MEPS). We assessed access to cancer care using the MEPS Experiences With Cancer Survey. We used multivariable logistic regression to compare access to general medical care among 2 groups of cancer survivors (those who reported having access to all necessary cancer care [n = 1088] and those who did not [n = 70]) with self-reported access to general medical care among people who had no history of cancer (n = 22 434)., Results: Of the 1158 cancer survivors, 70 (6.0%) reported that they did not receive all necessary cancer care. Adjusted analyses found that cancer survivors who reported not receiving all necessary cancer care were also less likely to report receiving general medical care (78.0%) than cancer survivors who reported having access to necessary cancer care (87.1%) and people who had no history of cancer (87.8%)., Conclusions: This study provides nationally representative data on the proportion of cancer survivors who have access to necessary cancer care and yields insight into factors that impede survivors' access to both cancer care and general medical care. This study is a reference for future work on access to care., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Both the United States and Canada offer government-financed health insurance for the elderly, but few studies have compared care at the end of life for cancer patients between the two systems., Methods: We identified care for non-small cell lung cancer (NSCLC) patients who died of cancer at age 65 years and older during 1999-2003. Patients were identified from US Surveillance, Epidemiology, and End Results (SEER)-Medicare data (N = 13,533) and the Ontario Cancer Registry (N = 8100). Health claims during the last 5 months of life identified chemotherapy and emergency room use, hospitalizations, and supportive care. We estimated rates per person-months (PM) for short-term survivors (died <6 months after diagnosis) and longer-term survivors (died ≥6 months after diagnosis), adjusting for demographic differences. To test whether monthly rates in Ontario were statistically significantly different from the United States, standardized differences were computed, and a 99% confidence interval (CI) was constructed to account for the multiple tests performed. All statistical tests were two-sided., Results: Rates of chemotherapy use were statistically significantly higher for SEER-Medicare patients than Ontario patients in every month before death (short-term survivors at 5 months before death: SEER-Medicare, 33.2 patients per 100 PM vs Ontario, 9.5 per 100 PM, rate difference = 23.7 per 100 PM, 99% CI = 18.3 to 29.1 per 100 PM, P < .001; longer-term survivors at 5 months before death: SEER-Medicare, 24.4 patients per 100 PM vs Ontario, 14.5 per 100 PM, rate difference = 9.9 per 100 PM, 99% CI = 7.7 to 12.1 per 100 PM, P <. 001). During the last 30 days of life, fewer SEER-Medicare than Ontario patients were hospitalized (short-term survivors, 49.9 vs 78.6 patients per 100 PM, rate difference = 28.6 per 100 PM, 95% CI = 22.9 to 34.4 per 100 PM, P <. 001; longer-term survivors, 44.1 vs 67.1 patients per 100 PM, rate difference = 23.0 per 100 PM, 95% CI = 18.5 to 27.5 per 100 PM, P < .001)., Conclusions: NSCLC patients in both Ontario and the United States used extensive end-of-life care. Limited availability of hospice care in Ontario and differing attitudes between the United States and Ontario regarding end-of-life care may explain the differences in practice patterns.

PURPOSE In the 1930s, the federally sponsored Home Owners' Loan Corporation (HOLC) used racial composition in its assessment of areas worthy of receiving loans. Neighborhoods with large proportions of Black residents weremapped in red (ie, redlining) and flagged as hazardous for mortgage financing. Redlining created a platform for systemic disinvestment in these neighborhoods, leading to barriers in access to resources that persist today. We investigated the association between residing in areaswith differentHOLC ratings and receipt of quality cancer care and outcomes among individuals diagnosed with colon cancer--a leading cause of cancer deaths amenable to early detection and treatment. METHODS Individuals who resided in zip code tabulation areas in 196 cities with HOLC rating and were diagnosed with colon cancer from 2007 to 2017 were identified from the National Cancer Database and assigned a HOLC grade (A, best; B, still desirable; C, definitely declining; and D, hazardous and mapped in red). Multivariable logistic regression models investigated association of area-level HOLC grade and late stage at diagnosis and receipt of guideline-concordant care. The product-limit method evaluated differences in time to adjuvant chemotherapy. Multivariable Cox proportional hazard models investigated differences in overall survival (OS). RESULTS There were 149,917 patients newly diagnosed with colon cancer with a median age of 68 years. Compared with people living in HOLC A areas, people living in HOLC D areas were more likely to be diagnosed with late-stage disease (adjusted odds ratio, 1.06 [95% CI, 1.00 to 1.12]). In addition, people living in HOLC B, C, and D areas had 8%, 16%, and 24% higher odds of not receiving guidelineconcordant care, including lower receipt of surgery, evaluation of ≥12 lymph nodes, and chemotherapy. People residing in HOLC B, C, or D areas also experienced delays in initiation of adjuvant chemotherapy after surgery. People residing in HOLC C (adjusted hazard ratio [aHR], 1.09 [95% CI, 1.05 to 1.13]) and D (aHR, 1.13 [95% CI, 1.09 to 1.18]) areas had worse OS, including 13% and 20% excess risk of death for individuals diagnosed with early- and 6% and 8% for late-stage disease for HOLC C and D, respectively. CONCLUSION Historical housing discrimination is associated with worse contemporary access to colon cancer care and outcomes. [ABSTRACT FROM AUTHOR]

Despite advances in cancer control—prevention, screening, diagnosis, treatment, and survivorship—racial disparities in cancer incidence and survival persist and, in some cases, are widening in the United States. Since 2020, there's been growing recognition of the role of structural racism, including structurally racist policies and practices, as the main factor contributing to historical and contemporary disparities. Structurally racist policies and practices have been present since the genesis of the United States and are also at the root of environmental injustices, which result in disproportionately high exposure to environmental hazards among communities targeted for marginalization, increased cancer risk, disruptions in access to care, and worsening health outcomes. In addition to widening cancer disparities, environmental injustices enable the development of polluting infrastructure, which contribute to detrimental health outcomes in the entire population, and to climate change, the most pressing public health challenge of our time. In this commentary, we describe the connections between climate change and cancer through an Environmental Justice perspective (defined as the fair treatment and meaningful involvement of people of all racialized groups, nationalities, or income, in all aspects, including development, implementation, and enforcement, of policies and practices that affect the environment and public health), highlighting how the expertise developed in communities targeted for marginalization is crucial for addressing health disparities, tackling climate change, and advancing cancer control efforts for the entire population. [ABSTRACT FROM AUTHOR]

The article highlights the cancer mortality rates in rural areas in the U.S. Topics include the rural-urban disparities, and the availability of cancer care treatments; the use of approaches to overcome issues in rural populations, including community-based coalitions and outreach, enhanced oncology care infrastructure, and affiliations with local practices.

Background: Lack of health insurance coverage is associated with poor access and receipt of cancer care and survival in the United States. Disruptions in coverage are common among low-income populations, but little is known about associations of disruptions with cancer care, including prevention, screening, and treatment, as well as outcomes of stage at diagnosis and survival.Methods: We conducted a systematic review of studies of health insurance coverage disruptions and cancer care and outcomes published between 1980 and 2019. We used the PubMed, EMBASE, Scopus, and CINAHL databases and identified 29 observational studies. Study characteristics and key findings were abstracted and synthesized qualitatively.Results: Studies evaluated associations between coverage disruptions and prevention or screening (31.0%), treatment (13.8%), end-of-life care (10.3%), stage at diagnosis (44.8%), and survival (20.7%). Coverage disruptions ranged from 4.3% to 32.8% of patients age-eligible for breast, cervical, or colorectal cancer screening. Between 22.1% and 59.5% of patients with Medicaid gained coverage only at or after cancer diagnosis. Coverage disruptions were consistently statistically significantly associated with lower receipt of prevention, screening, and treatment. Among patients with cancer, those with Medicaid disruptions were statistically significantly more likely to have advanced stage (odds ratios = 1.2-3.8) and worse survival (hazard ratios = 1.28-2.43) than patients without disruptions.Conclusions: Health insurance coverage disruptions are common and adversely associated with receipt of cancer care and survival. Improved data infrastructure and quasi-experimental study designs will be important for evaluating the associations of federal and state policies on coverage disruptions and care and outcomes. [ABSTRACT FROM AUTHOR]

Little is known about the competing effects of increasing prescription drug costs and expansions in insurance coverage on prescription drug access and whether trends vary for adults with and without a cancer history. Using the 2010-2015 National Health Interview Survey, we examined trends in limited prescription drug access, operationalized as forgoing needed prescription drugs because of cost. The percentages of adults age 18 to 64 years with limited prescription drug access decreased over time: predicted margins from multivariable logistic regression models were 13.8% in 2010 vs 8.6% in 2015 for cancer survivors and 11.0% vs 6.8% for adults without a cancer history (adjusted odds ratio [aOR] for trend = 0.89, 95% confidence interval [CI] = 0.88 to 0.90). Access changed little for adults age 65 years and older. Among adults age 18 to 64 years, cancer survivors were more likely than those without a cancer history to report limited access to any prescription drug in all years (aOR from multivariable logistic regression model = 1.45, 95% CI = 1.31 to 1.61). However, trends did not differ by cancer history. Our findings suggest that expansions in health insurance coverage mitigated the effects of growing prescription drug costs to some extent for many individuals with and without a history of cancer. [ABSTRACT FROM AUTHOR]

Objectives: Cancer survivors require appropriate health care to manage their unique health needs. This study describes access to cancer care among cancer survivors in the United States and compares access to general medical care between cancer survivors and people who have no history of cancer. Methods: We assessed access to general medical care using the core 2011 Medical Expenditure Panel Survey (MEPS). We assessed access to cancer care using the MEPS Experiences With Cancer Survey. We used multivariable logistic regression to compare access to general medical care among 2 groups of cancer survivors (those who reported having access to all necessary cancer care [n = 1088] and those who did not [n = 70]) with self-reported access to general medical care among people who had no history of cancer (n = 22434). Results: Of the 1158 cancer survivors, 70 (6.0%) reported that they did not receive all necessary cancer care. Adjusted analyses found that cancer survivors who reported not receiving all necessary cancer care were also less likely to report receiving general medical care (78.0%) than cancer survivors who reported having access to necessary cancer care (87.1 %) and people who had no history of cancer (87.8%). Conclusions: This study provides nationally representative data on the proportion of cancer survivors who have access to necessary cancer care and yields insight into factors that impede survivors' access to both cancer care and general medical care. This study is a reference for future work on access to care. [ABSTRACT FROM AUTHOR]

Adolescent and young adult cancer survivors—those who were ages 15–39 at their first cancer diagnosis—have important health limitations. These survivors are at risk for higher health care expenditures and lost productivity, compared to adults without a history of cancer. Using Medical Expenditure Panel Survey data, we present nationally representative estimates of the economic burden among people who were diagnosed with cancer in adolescence or young adulthood. Our findings demonstrate that surviving cancer at this age is associated with a substantial economic burden. Compared to adults without a history of cancer, adolescent and young adult cancer survivors had excess annual medical expenditures of $3,170 per person and excess annual productivity losses of $2,250 per person. Multifaceted prevention strategies, including education and sustained intervention programs to ensure access to lifelong risk-based follow-up care, may be effective ways to improve the economic outcomes associated with cancer survivorship in this population. [ABSTRACT FROM AUTHOR]

Purpose. This study investigates the relationship between patterns of health behaviors and the use of cancer-screening tests while controlling for sociodemographic and health system factors. Design. Cross-sectional analysis of the 2000 National Health Interview (NHIS). Setting. Nationally representative sample. Subjects. Adults 50 years and older. Measures. Use of cancer-screening tests, health behaviors, sociodemographic factors, and health system factors from self-reported responses from the NHIS. Sixteen health behavior patterns were identified based on lifestyle recommendations for physical activity, tobacco use, alcohol consumption, and fruit and vegetable consumption. Results. Health behavior patterns, age, educational attainment, usual source of care, and health insurance were significantly associated with the use of breast, cervical, and colorectal cancer screening (p < .05). Approximate R² for the four models ranged from .067 for colorectal cancer screening in women to .122 for cervical cancer screening Having a usual source of care was the strongest correlate of screening the magnitude of associations for health behavior patterns and demographic variables and screening was similar and much smaller than those for usual source of care. Conclusion. These findings demonstrate relationships between patterns of multiple health behaviors and use of recommended cancer-screening tests, even when accounting for factors known to influence test use. This suggests potential for addressing cancer screening in the context of multiple behavior change interventions once barriers to health care access are removed. [ABSTRACT FROM AUTHOR]

Proposals for expanding Medicare insurance coverage to uninsured Americans approaching the Medicare eligibility age of sixty-five has been the subject of intense debate. We undertook this study to assess cancer survival differences between uninsured patients younger than age sixty-five and older Medicare beneficiaries by using data from the National Cancer Database from the period 2004-16. The main outcomes were survival at one, two, and five years for sixteen cancer types in 1,206,821 patients. We found that uninsured patients ages 60-64 were nearly twice as likely to present with late-stage disease and were significantly less likely to receive surgery, chemotherapy, or radiotherapy than Medicare beneficiaries ages 66-69, despite lower comorbidity among younger patients. Compared with older Medicare patients, younger uninsured patients had strikingly lower five-year survival across cancer types. For instance, five-year survival in younger uninsured patients with late-stage breast or prostate cancer was 5-17 percent lower than that among older Medicare patients. We conclude that survival after a diagnosis of cancer is considerably lower in younger uninsured patients than in older Medicare patients. Expanding comprehensive health insurance coverage to people approaching Medicare age eligibility may improve cancer outcomes in the US. [ABSTRACT FROM AUTHOR]