ACS Research Highlights

Better Cancer Survival Requires Better Health Insurance

ACS researchers show that inadequate health insurance continues to be life-threatening to people diagnosed with cancer. 

The Challenge

Studies from the early 2000s showed that people who did not have any health insurance (uninsured) or who did not have enough to meet their needs (underinsured) were more likely to be diagnosed with cancer at a later stage and were more likely to die from it. 

Those previous studies had relatively short follow-ups, and few comprehensively examined the stage of diagnosis and survival. Plus, the use of cancer screening has increased in the past decade, and new, effective cancer treatments continue to be introduced.

This outdated information motivated the American Cancer Society (ACS) Health Science team to get more up-to-date info on the effect of not having enough, or any, health insurance coverage on cancer outcomes.

The Research

ACS Health Science researcher, Jingxuan Zhao, MPH, and her colleagues examined current data from the National Cancer Database to understand the relationship between health insurance coverage with both the stage of cancer at diagnosis and overall survival. The study was published in the ACS flagship journal CA: Cancer Journal for Clinicians.

The researchers looked at the health insurance status of over 1.5 million men and women who had been diagnosed with 1 of 19 most common types of cancer between the ages of 18 to 64. 

Glossary for Nonscientists

Featured Term:
Survival rate

The percentage of people who are alive at a certain time after diagnosis of a life-threatening disease, like cancer. The survival rate doesn’t determine how long a person will live after a diagnosis of cancer, but it may help people better understand how likely it is that treatment will be successful.

For cancer, it’s common to see a 5-year period after diagnosis as the marker, referred to as a 5-year survival rate.

In that group, at the time of diagnosis (between 2010 and 2013):

  • 73% had private health insurance (such as from an employer)
  • 11% had Medicaid (health insurance for some people with low income)
  • 7% had Medicare (insurance for people aged 65 and older or for people of any age with certain  disabilities)
  • 7% were uninsured
  • 2% had dual Medicare/Medicaid, meaning they were eligible for health care coverage from both Medicare and Medicaid.

The researchers also noted these age and racial disparities linked with health insurance coverage:

  • People without private health insurance are more likely to be younger and live in areas with high levels of poverty, compared with those who have private health insurance.
  • People with a new diagnosis of cancer who are Black or Hispanic were more likely to be uninsured. 

Zhao and the team noted two key findings from the research. Compared to people with private health insurance:

  1. People who lack health insurance or who are covered by Medicaid are more likely to receive a diagnosis of cancer that's a later stage.
  2. The survival rate is worse for uninsured people.

For the United States to improve access to health care—specifically to cancer care—requires improving access to comprehensive health insurance. Because that’s what research keeps showing—health insurance is critical for ensuring access to care throughout the cancer care continuum—which means getting recommended cancer screenings, timely diagnosis, and quality treatment.”

Jingxuan Zhao, MPH
Health Services Research
Surveillance and Health Equity Science
American Cancer Society

Later Stage at Diagnosis - Key Findings

Compared to those with private health insurance, people without it or who are covered by Medicaid are more likely to be diagnosed with cancer at Stage III or Stage IV, when the cancer is typically harder to treat, more costly, and more difficult to survive.

The researchers also found the disparities in stage at diagnosis based on health insurance status were higher for colorectal cancer and female breast cancer at ages 50 to 64 compared to ages 18 to 64. Since 50 to 64 is the age group for which screening is most widely emphasized these findings indicate the importance of health insurance for getting access to cancer screenings.

This graphic shows that of all of the people in the study who were recently diagnosed with cancer, those with private health insurance (shown in dark blue) have a higher percentage of people diagnosed at an early stage (stages I and II) when the cancer is typically less complicated to treat. Those with private health insurance also had fewer people with a late-stage (stage III and IV) diagnosis when treatment tends to be more complicated and survival rates are lower.

Survival Rates - Key Findings

Uninsured people with Stage I disease had worse survival than privately insured people with Stage II disease for:

  • All the studied cancers combined that are described by stages.
  • For 6 types of cancer separately: colorectal, esophagus, liver, non-Hodgkin lymphoma, oral cavity, and prostate.

People covered by Medicaid, Medicare, or dual Medicare/Medicaid and those without health insurance had worse 2-year, 5-year, and 8-year survival after a cancer diagnosis for all 19 of the cancers studied.

Patients who were uninsured had worse survival for 12 of 17 stageable cancers and had worse survival for leukemia and brain tumors.

Perhaps not surprisingly, another ACS study that Zhao contributed to, found that people living in Medicaid Expansion states under the Affordable Care Act had greater improvements in 2-year survival after a cancer diagnosis compared to people living in nonexpansion states. 

The US National Cancer Database is a nationwide, hospital-based cancer registry jointly sponsored by the ACS and the American College of Surgeons.

Several other ACS researchers as co-authors: Xuesong Han, PhD, Leticia Nogueira, MPH, PhD, Ahmedin Jemal, DVM, PhD, and Robin Yabroff, PhD, MBA. Previous ACS researcher Stacey Fedewa, MPH, PhD, was also a co-author. She is now an assistant professor at Emory University.

This graphic shows that among people with any type of cancer that can be staged, people with Medicaid (gold) or who were uninsured (teal blue) had lower 5-year survival rates compared with those with private health insurance (dark blue).

Why It Matters

While the number of uninsured Americans has decreased since the Affordable Care Act, and with the increases in affordable healthcare options, more than 30 million people remain uninsured.

“Cancer is the second leading cause of death in the United States. Those without resources for health insurance often endure more side effects and are dying because they can't afford screening or treatment,” Zhao says. “Continuing national and state efforts to expand access to affordable health insurance options is crucial for seeing better outcomes for more Americans. We hope this research, along with others, allows both the public and private sectors to continue discussions around how to improve access to comprehensive health insurance,” Zhao continues.

What the ACS Is Doing to Help People Without Health Insurance

The American Cancer Society Cancer Action Network (ACS CAN) empowers advocates across the country to make their voices heard and influence evidence-based public policy change to reduce the cancer burden for everyone. ACS CAN was founded to directly lobby for the goals of ACS.

Here are a few of the policies ACS CAN supports that will reduce the cost of cancer for people without health insurance:

  • Expanding Medicaid in the 10 remaining US states that have not done so (Alabama, Georgia, Florida, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming). Those states represent 2.1 million people who should be able to see a doctor but can’t afford to do so.
  • Limiting the sale of noncomprehensive health insurance plans. Some of these are called Short-term Limited Duration (STLD) health care plans.
  • Improving access to and ensuring long-term sustainable payment of patient navigation services.