A study investigating the effect of health insurance status on cancer care in different communities was released this past November in the publication “Cancer,” a peer-reviewed oncology journal. Among the authors of the study is Sandra Wong, interim Norris Cotton Cancer Center service line director and vice president and chair of surgery at Dartmouth-Hitchcock Medical Center.
The study found that disadvantaged communities saw greater benefits from health insurance than more advantaged communities. However, insured patients from more advantaged communities generally received better cancer care than insured patients in disadvantaged communities. There was a correlation between a community’s advantage level and the outcome of cancer care, such as the survival rate, and while health insurance appeared to lessen this relationship, it did not fully eliminate the impact of social determinants of health that exist in a patient’s surrounding environment.
“The question that came from [the study] was why the effect was different,” Wong said. “[The study] also really highlights the disparity inherent in things that affect your environment besides medical care.”
Wong said that before the study, she and her team had no idea that the political climate surrounding health insurance would change after the results were released. During his campaign for presidency, President Donald Trump emphasized that he would repeal the Affordable Care Act after assuming office. Trump has since been criticized for pushing for the act’s repeal without providing a suitable replacement.
“The interpretation of the findings have definitely changed due to the change in the political climate,” Wong said. “One of the things we were interested in looking at had a lot to do with analyzing the impact of the Affordable Care Act. We were doing an evaluation of [the act], rather than looking at implications of not having it.”
Wong said that the study looked into the emphasis of the Affordable Care Act on the outcome of cancer care as well as the community level programs that improved health. She said that there was a question about the relationship between quality of insurance coverage and where a person lives.
The Dartmouth Institute for Health Policy and Clinical Practice professor of medicine H. Gilbert Welch said that Wong’s study is the first that he has seen that asks about the effects of community influences on a disease. He said that there has been knowledge that social determinants are important to health, but that the study showed how this knowledge is being implied very concretely in a specific disease. Wong’s study ultimately emphasized the importance of community — individuals in a disadvantaged community are more likely to face negative outcomes than those in less disadvantaged communities, even if they have insurance, he said.
“I think it is important to point out that the community level issues are very important, and I suspect that people on both sides of the argument could see two different arguments here,” Welch said. “A conservative person might argue about jobs, while a liberal person would talk about insurance. The truth is that both are right. It is important that people have jobs, have meaning and have healthcare — it’s all important to their health.”
The Dartmouth Institute professor of economics Ellen Meara said that the significant feature of the study was the contrast between disadvantaged and advantaged counties and the social determinants. She said that individuals under Medicaid were usually the poorest group and that they were even more disadvantaged than the uninsured.
“In the current debate, I would read [the study results] as saying if we lose coverage due to repeal of the Affordable Care Act without other coverage, it’ll have a big impact on these disadvantaged areas,” Meara said.
Wong said that the study looked at insurance coverage on a national level in a variety of settings, which made their study unique from other studies that looked at insurance expansion on cancer care. A similar study by Massachusetts General Hospital surgeon John Mullen, among others, looked at how healthcare coverage impacted cancer treatment since the state reformed its healthcare system in 2006. She said that while the circumstances of the studies were different — national versus state — healthcare coverage increased and improved access to treatments for cancer and the treatments themselves.
“The results of my study showed the need to make sure that communities are provided for and that providing national programs is necessary,” Wong said.
