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.