Effects of being uninsured or underinsured and living in extremely poor neighborhoods on colon cancer care and survival in California: historical cohort analysis, 1996—2011
1 School of Social Work, University of Windsor, 401 Sunset Avenue, Windsor, Ontario, N9B 3P4, Canada
2 Department of Geography, University of Western Ontario, London, Ontario, Canada
3 Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
4 Department of Epidemiology and Biostatistics, and Robarts Research Institute, University of Western Ontario, London, Ontario, Canada
5 Windsor Regional Cancer Center and School of Medicine and Dentistry, Department of Medicine, Division of General Internal Medicine, University of Western Ontario, London, Ontario, Canada
6 Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Ontario, Canada
7 Windsor Regional Cancer Center, Windsor, Ontario, Canada
8 School of Social Work, University of Windsor, Windsor, Ontario, Canada
9 School of Social Work, University of Windsor, Windsor, Ontario, Canada
10 Division of General Surgery, Sunnybrook Health Sciences Center and cross appointed to the Departments of Surgery, and Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
BMC Public Health 2012, 12:897 doi:10.1186/1471-2458-12-897Published: 24 October 2012
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.
We 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.
Evidence 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.
Health 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.