Most previous studies comparing stage of cancer at diagnosis between Medicaid and non-Medicaid populations have not accounted for the patient's timing of enrollment in the Medicaid program in relation to the initial date of cancer diagnosis. Findings from this study indicate that Medicaid benefi ciaries having enrolled in the program at least 3 months before breast or cervical cancer diagnosis are significantly less likely to be seen with distant metastases on diagnosis than those enrolling in the Medicaid program shortly before, on, or after cancer diagnosis. Although these results reflect positively on the effectiveness of the Medicaid program in cancer prevention, they also provide support to further enhance cancer-screening efforts in the Medicaid population.
A number of studies have shown that uninsured women and those insured through the Medicaid program are more likely than others to be seen with advanced stages of cancer on diagnosis.1–4 Stage of cancer at diagnosis is an important prognostic factor, given the high rates of cure when cancer is diagnosed at early stages. Stage is also an important marker for quality of care,5,6 because the use of screening services is associated with early detection of cancer for a number of anatomic sites, including breast and cervical cancer.
The Medicaid program is mostly comprised of children and women of childbearing age, with incomes less than the federal poverty level (FPL). It also provides coverage to individuals with disabilities and to low-income elderly individuals. Given the signifi cant representation of women in the Medicaid program, and because breast and cervical cancers are amenable to screening, it was deemed appropriate to examine the role of Medicaid in breast and cervical cancer prevention.
The Medicaid population includes individuals who join the program on being diagnosed with a major health condition, such as cancer. The decision to apply for the Medicaid program is likely to be made if the individual is uninsured, underinsured, with low income, on losing employment because of their ailment(s), and on impoverishment. As a result, it can be hypothesized that these individuals are likely to be sicker than individuals with health insurance, including those insured through Medicaid, presumably because of their very limited access to preventive and routine health care services.
It is of interest to further our understanding on the health care needs of individuals on their point of entry into Medicaid, because the Medicaid program constitutes a safety net program for the most vulnerable segments of the population—the poorest and the sickest.7 In turn, this implies a greater burden of disease borne by the Medicaid program. From the perspective of policy analysis, particularly in studying health care outcomes among Medicaid beneficiaries, accounting for individuals recently enrolled in the program would yield results that may not be generalized to the Medicaid population overall, especially when the outcome(s) of interest is(are) associated with prior access to and use of routine, preventive, and/or screening services.
Previous studies examining differences in stage of cancer by Medicaid status have relied on state tumor registries or linked tumor registries and Medicaid files, and they are likely to have identified Medicaid status at the time of diagnosis or any time during the study period, without accounting for the timing of enrollment in the Medicaid program in relation to the initial date of cancer diagnosis. For cancers that are amenable to screening, the timing of enrollment in a health insurance plan is an important factor in studying the quality and effectiveness of the plan in providing enrollees with the appropriate screening and health maintenance services. In fact, screening rates for breast and cervical cancer are considered among the indicators of Healthy People 2010,8 as well as that of the Health Employer Data Information System (HEDIS®),9 an instrument designed to evaluate health plans.
This study compares the stage of breast and cervical cancer at diagnosis between Medicaid and non-Medicaid women and between Medicaid beneficiaries who have participated in the program for a considerable length of time before their cancer diagnoses and those who joined the program shortly before, on, or after their cancer diagnoses.
Siran M. Koroukian, PhD, Senior Instructor, Department of Epidemiology and Biostatistics, School of Medicine, Case Western Reserve University, Cleveland, Ohio.
Corresponding author: Siran M. Koroukian, PhD, Senior Instructor, Department of Epidemiology and Biostatistics, School of Medicine, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106-4945 (e-mail: firstname.lastname@example.org).
Dr. Koroukian was supported by a postdoctoral training grant from the National Cancer Institute at the time the study was conducted (#F32 CA84621).
Cancer incidence data were obtained from the Ohio Cancer Incidence Surveillance system (OCISS), Ohio Department of Health. Use of these data does not imply that the Ohio Department of Health either agrees or disagrees with any presentation, analyses, interpretations, or conclusions. Information about the OCISS may be obtained at http://odh.state.oh.us/ODHPrograms/CI_SURV/ci_surv1.htm.
These results were presented in part at the annual meeting of the National Association of Health Data Organizations (NAHDO), December 3, 2001, Washington, DC.
The author thanks Dr. Gregory S. Cooper of the Department of Medicine and the Department of Epidemiology and Biostatistics, Case Western Reserve University, and Ms. Georgette Haydu of the Ohio Cancer Incidence Surveillance System, the Ohio Department of Health and Dr. Rosemary Chaudry, Bureau of Health Plan Policy, Ohio Department of Job and Family Services, for their review of earlier versions of this manuscript and their helpful comments.