DISCUSSION
In this nationally representative study of patients diagnosed with advanced but treatable OCSCC (i.e. T4a disease), we found that prior to 2014, patients who were uninsured or with Medicaid insurance were significantly less likely to receive curative-intent surgery than patients with private insurance. The ACA expansion in 2014 seemed to mitigate this disparity for both sets of patients. Understandably, patients with T4b disease were less likely to receive definitive treatment due to advanced disease not amenable to surgical resection.
Although previous studies have shown disparities in cancer outcomes based on patient insurance status, to the best of our knowledge, this is the first national study to explore the interplay between insurance (including Medicaid coverage) and the receipt of definitive treatment in advanced OCSCC. 8,9,11,12 Expansion of Medicaid coverage, and the provision of subsidies for individuals below the poverty line as legislated by the ACA, is a good first step to addressing the morbidity and mortality associated with OCSCC. These findings underscore the need for ongoing efforts that support equality in the medical care received by different factions of the American population, including those with differing insurance coverage.
It has been previously shown that patients who are uninsured or Medicaid-insured often present with more advanced disease at the time of diagnosis. This increased risk for presenting with late-stage disease has been attributed to a lack of access to screening procedures. For instance, oral cavity cancer is typically detected during routine dental cleanings, and Medicaid covers only limited dental care for patients under the age of 21.13 While controlling for stage of disease, our findings suggest that patients with Medicaid insurance in the pre-ACA period were less likely to receive definitive treatment than those with private insurance.
There are several possible explanations for this observed difference. Firstly, Medicaid patients face barriers to accessing treatment.14 The relatively lower reimbursement rates of Medicaid insurance are linked to higher rates of physician refusal to provide complex cancer care. The findings of the 2013 National Electronic Health Records Survey is consistent with this notion, and found that the percentage of physicians accepting new patients on Medicaid (68.9%) was much lower than that accepting patients on Medicare (83.7%) and on private insurance (84.7%).15There are several indirect and uncovered costs that can be burdensome for cancer patients. Analysis of commercially-insured individuals revealed that the average medical costs of oral cavity cancers in the first year after diagnosis was $79,151, which is significantly higher than the cost to treat other cancers ($31,559-$65,123).16,17,18 Furthermore, individuals who received multi-modality therapy (surgery, radiation and chemotherapy) averaged $153,892 during the first year after diagnosis.18 These medical costs are approximately twice any other reported cancer costs. For patients that survived the first year after diagnosis, indirect costs of short-term disability were also high ($7,386 higher) for employees with oral cavity cancer, than for matched employees without cancer.18 Not all insurance plans are equal; with differences in deductibles, copayments or coinsurance fees, the financial toxicity of cancer can be prohibitive for patients seeking medical care. Fortunately, the 2014 ACA expansion did seem to sufficiently reduce the likelihood that uninsured and Medicaid-insured patients would face such prohibitive restrictions to receiving definitive treatment. These findings are novel, and may serve as proof of principle that the expansion of Medicaid has tangible benefits for head and neck cancer patients.
Other barriers to receiving care include a lack of transportation to medical or dental appointments, the inability to leave work to attend appointments, presence of other comorbidities, treatment at academic versus non-academic hospitals, urban versus rural settings, as well as surgeon case volumes.13,18 It is possible that patients who are uninsured or on Medicaid, who are treated at smaller, rural, or non-academic institutions, are less likely to be offered definitive treatment due to a lack of resources or surgeon experience with performing near-total or total glossectomies with advanced reconstruction.19 Further research correlating social determinants of health and individual-level data on socioeconomic factors with cancer care is required for this unique cohort of patients.