Mediation of the effects of living in extremely poor neighborhoods by health insurance: breast cancer care and survival in California, 1996 to 2011

International Journal for Equity in Health

Madhan K Balagurusamy⁵  Caroline Hamm⁶  Guangyong Zou¹  Eric J Holowaty⁴  Isaac N Luginaah²  Kevin M Gorey³ 

[1] Department of Epidemiology and Biostatistics, University of Western Ontario and Scientist, Robarts Research Institute, London, Ontario, Canada;Department of Geography, University of Western Ontario, London, Ontario, Canada;School of Social Work, University of Windsor, 401 Sunset Avenue, Windsor, Ontario, N9B 3P4, Canada;Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada;Statistician and Research Associate, School of Social Work, University of Windsor, Windsor, Ontario, Canada;Medical Oncologist, Windsor Regional Cancer Center, School of Medicine and Dentistry, Department of Medicine, Division of General Internal Medicine, University of Western Ontario, London, Ontario, Canada

关键词: California, United States;    Health care reform;    Social capital;    Survival;    Breast cancer care;    Poverty;    Health insurance;   

Others  :  825912
DOI  :  10.1186/1475-9276-12-6

 received in 2012-07-31, accepted in 2013-01-07,  发布年份 2013

【 摘 要 】

Background

We examined the mediating effect of health insurance on poverty-breast cancer care and survival relationships and the moderating effect of poverty on health insurance-breast cancer care and survival relationships in California.

Methods

Registry data for 6,300 women with breast cancer diagnosed between 1996 and 2000 and followed until 2011 on stage at diagnosis, surgeries, adjuvant treatments and survival were analyzed. Socioeconomic data were obtained for residences from the 2000 census to categorize neighborhoods: high poverty (30% or more poor), middle poverty (5%-29% poor) and low poverty (less than 5% poor). Primary payers or health insurers were Medicaid, Medicare, private or uninsured.

Results

Evidence of survival mediation was observed for women with node negative breast cancer. The apparent effect of poverty disappeared in the presence of Medicare or private health insurance. Women who were so insured were advantaged on 8-year survival compared to the uninsured or those insured by Medicaid (OR = 1.89). Evidence of payer moderation by poverty was also observed for women with node negative breast cancer. The survival advantaging effect of Medicare or private insurance was stronger in low poverty (OR = 1.81) than it was in middle poverty (OR = 1.57) or in high poverty neighborhoods (OR = 1.16). This same pattern of mediated and moderated effects was also observed for early stage at diagnosis, shorter waits for adjuvant radiation therapy and for the receipt of sentinel lymph node biopsies. These findings are consistent with the theory that more facilitative social and economic capital is available in low poverty neighborhoods, where women with breast cancer may be better able to absorb the indirect and direct, but uncovered, costs of care. As for treatments, main protective effects as well as moderator effects indicative of protection, particularly in high poverty neighborhoods were observed for women with private health insurance.

Conclusions

America’s multi-tiered health insurance system mediates the quality of breast cancer care. The system is inequitable and unjust as it advantages the well insured and the well to do. Recent health care reforms ought to be enacted in ways that are consistent with their federal legislative intent, that high quality health care be truly available to all.

【 授权许可】

   
2013 Gorey et al; licensee BioMed Central Ltd.

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