Abstract
BackgroundWe examined the mediating effects of health insurance on poverty-colon cancer care and survival relationships and the moderating effects of poverty on health insurance-colon cancer care and survival relationships among women and men in California.MethodsWe analyzed registry data for 3,291 women and 3,009 men diagnosed with colon cancer between 1996 and 2000 and followed until 2011 on lymph node investigation, stage at diagnosis, surgery, chemotherapy, wait times and survival. We obtained socioeconomic data for individual residences from the 2000 census to categorize the following neighborhoods: high poverty (30% or more poor), middle poverty (5-29% poor) and low poverty (less than 5% poor). Primary health insurers were Medicaid, Medicare, private or none.ResultsEvidence of mediation was observed for women, but not for men. For women, the apparent effect of poverty disappeared in the presence of payer, and the effects of all forms of health insurance seemed strengthened. All were advantaged on 6-year survival compared to the uninsured: Medicaid (RR = 1.83), Medicare (RR = 1.92) and private (RR = 1.83). Evidence of moderation was also only observed for women. The effects of all forms of health insurance were stronger for women in low poverty neighborhoods: Medicaid (RR = 2.90), Medicare (RR = 2.91) and private (RR = 2.60). For men, only main effects of poverty and payers were observed, the advantaging effect of private insurance being largest. Across colon cancer care processes, Medicare seemed most instrumental for women, private payers for men.ConclusionsHealth insurance substantially mediates the quality of colon cancer care and poverty seems to make the effects of being uninsured or underinsured even worse, especially among women in the United States. These findings are consistent with the theory that more facilitative social and economic capital is available in more affluent neighborhoods, where women with colon cancer may be better able to absorb the indirect and direct, but uncovered, costs of care.
Highlights
IntroductionThe Canadian survival advantage was systematically replicated across diverse low-income Canadian and US contexts through the 1990s [2,3,4,5,6,7,8], culminating in a recent study of colon cancer treatment accessibility and survival in Toronto, Ontario, and San Francisco, California that followed its cohorts until 2006 [9]
We examined the mediating effects of health insurance on poverty-colon cancer care and survival relationships and the moderating effects of poverty on health insurance-colon cancer care and survival relationships among women and men in California
People with colon cancer living in high poverty California neighborhoods were nearly twice as likely to be uninsured, five to nearly seven times as likely to be primarily insured by Medicaid, but only two-thirds to half as likely to be so covered by a private insurer as were their counterparts in low poverty neighborhoods
Summary
The Canadian survival advantage was systematically replicated across diverse low-income Canadian and US contexts through the 1990s [2,3,4,5,6,7,8], culminating in a recent study of colon cancer treatment accessibility and survival in Toronto, Ontario, and San Francisco, California that followed its cohorts until 2006 [9]. More inclusive health insurance in Canada was advanced as the most plausible explanation All of these studies were ecological with respect to the measurement of socioeconomic status (SES). They typically used census tract data to define low-income neighborhoods where cancer patients lived, their lowest income areas only ranged from 10% to 20% poor. Recent synthetic and exploratory analyses have suggested the potential great policy importance of such study [13,14] and studies of colon cancer care may be instructive in such contexts for several reasons
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