Disparities Report: Disparities Among Minority Women With Breast Cancer Living in Impoverished Areas of California

BACKGROUND

Interaction effects of poverty and health care insurance coverage on overall survival rates of breast cancer among women of color and non-Hispanic white women were explored.

METHODS

We analyzed California registry data for 2,024 women of color (black, Hispanic, Asian, Pacific Islander, American Indian, or other ethnicity) and 4,276 non-Hispanic white women (Anglo-European ancestries and no Hispanic-Latin ethnic backgrounds) diagnosed with breast cancer between the years 1996 and 2000 who were then followed until 2011. The 2000 US census categorized rates of neighborhood poverty. Health care insurance coverage was either private, Medicare, Medicaid, or none. Cox regression was used to model rates of survival.

RESULTS

A 3-way interaction between ethnicity, health care insurance coverage, and poverty was observed. Women of color inadequately insured and living in poor or near-poor neighborhoods in California were the most disadvantaged. Women of color adequately insured and who lived in such neighborhoods in California were also disadvantaged. The incomes of such women of color were typically lower than the incomes of non-Hispanic white women.

CONCLUSIONS

Women of color with or without insurance coverage are disadvantaged in poor and near-poor neighborhoods of California. Such women may be less able to bare the indirect, direct, or uncovered costs of health care for breast cancer treatment.

Care and survival of Mexican American women with node negative breast cancer: historical cohort evidence of health insurance and barrio advantages

We hypothesized 3-way ethnicity by barrio by health insurance interactions such that the advantages of having adequate health insurance were greatest among Mexican American (MA) women who lived in barrios. Barrios were neighborhoods with relatively high concentrations of MAs (60% or more). Data were analyzed for 194 MA and 2,846 non-Hispanic white women diagnosed with, very treatable, node negative breast cancer in California between 1996 and 2000 and followed until 2011. Significant interactions were observed such that the protective effects of Medicare or private health insurance on radiation therapy access and long term survival were largest for MA women who resided in MA barrios, neighborhoods that also tended to be extremely poor. These paradoxical findings are consistent with the theory that more facilitative social and economic capital available to MA women in barrios enables them to better absorb the indirect and direct, but uncovered, costs of breast cancer care.

Multiplicative disadvantage of being an unmarried and inadequately insured woman living in poverty with colon cancer: historical cohort exploration in California

BACKGROUND

Many Americans diagnosed with colon cancer do not receive indicated chemotherapy. Certain unmarried women may be particularly disadvantaged. A 3-way interaction of the multiplicative disadvantages of being an unmarried and inadequately insured woman living in poverty was explored.

METHODS

California registry data were analyzed for 2,319 women diagnosed with stage II to IV colon cancer between 1996 and 2000 and followed until 2014. Socioeconomic data from the 2000 census classified neighborhoods as high poverty (≥30% of households poor), middle (5-29%) or low poverty (<5% poor). Primary health insurance was private, Medicare, Medicaid or none. Comparisons of chemotherapy rates used standardized rate ratios (RR). We respectively used logistic and Cox regression models to assess chemotherapy and survival.

RESULTS

A statistically significant 3-way marital status by health insurance by poverty interaction effect on chemotherapy receipt was observed. Chemotherapy rates did not differ between unmarried (39.0%) and married (39.7%) women who lived in lower poverty neighborhoods and were privately insured. But unmarried women (27.3%) were 26% less likely to receive chemotherapy than were married women (37.1%, RR = 0.74, 95% CI 0.58, 0.95) who lived in high poverty neighborhoods and were publicly insured or uninsured. When this interaction and the main effects of health insurance, poverty and chemotherapy were accounted for, survival did not differ by marital status.

CONCLUSIONS

The multiplicative barrier to colon cancer care that results from being inadequately insured and living in poverty is worse for unmarried than married women. Poverty is more prevalent among unmarried women and they have fewer assets so they are probably less able to absorb the indirect and direct, but uncovered, costs of colon cancer care. There seem to be structural inequities related to the institutions of marriage, work and health care that particularly disadvantage unmarried women that policy makers ought to be cognizant of as future reforms of the American health care system are considered.

Lack of access to chemotherapy for colon cancer: multiplicative disadvantage of being extremely poor, inadequately insured and African American

Background

Despite evidence of chemotherapy’s ability to cure or comfort those with colon cancer, nearly half of such Americans do not receive it. African Americans (AA) seem particularly disadvantaged. An ethnicity by poverty by health insurance interaction was hypothesized such that the multiplicative disadvantage of being extremely poor and inadequately insured is worse for AAs than for non-Hispanic white Americans (NHWA).

Methods

California registry data were analyzed for 459 AAs and 3,001 NHWAs diagnosed with stage II to IV colon cancer between 1996 and 2000 and followed until 2011. Socioeconomic data from the 2000 census categorized neighborhoods: extremely poor (≥ 30% of households poor), middle (5-29% poor) and low poverty (< 5% poor). Participants were randomly selected from these poverty strata. Primary health insurers were Medicaid, Medicare, private or none. Chemotherapy rates were age and stage-adjusted and comparisons used standardized rate ratios (RR). Logistic and Cox regressions, respectively, modeled chemotherapy receipt and long term survival.

Results

A significant 3-way ethnicity by poverty by health insurance interaction effect on chemotherapy receipt was observed. Among those who did not live in extremely poor neighborhoods and were adequately insured privately or by Medicare, chemotherapy rates did not differ significantly between AAs (37.7%) and NHWAs (39.5%). Among those who lived in extremely poor neighborhoods and were inadequately insured by Medicaid or uninsured, AAs (14.6%) were nearly 60% less likely to receive chemotherapy than were NHWAs (25.5%, RR = 0.41). When the 3-way interaction effect as well as the main effects of poverty, health insurance and chemotherapy was accounted for, survival rates of AAs and NHWAs were the same.

Conclusions

The multiplicative barrier to colon cancer care that results from being extremely poor and inadequately insured is worse for AAs than it is for NHWAs. AAs are more prevalently poor, inadequately insured, and have fewer assets so they are probably less able to absorb the indirect and direct, but uncovered, costs of colon cancer care. Policy makers ought to be cognizant of these factors as they implement the Affordable Care Act and consider future health care reforms.

Health insurance mediation of the Mexican American non-Hispanic white disparity on early breast cancer diagnosis

We examined health insurance mediation of the Mexican American (MA) non-Hispanic white (NHW) disparity on early breast cancer diagnosis. Based on social capital and barrio advantage theories, we hypothesized a 3-way ethnicity by poverty by health insurance interaction, that is, that 2-way poverty by health insurance interaction effects would differ between ethnic groups. We secondarily analyzed registry data for 303 MA and 3,611 NHW women diagnosed with breast cancer between 1996 and 2000 who were originally followed until 2011. Predictors of early, node negative (NN) disease at diagnosis were analyzed. Socioeconomic data were obtained from the 2000 census to categorize neighborhood poverty: high (30% or more of the census tract households were poor), middle (5% to 29% poor) and low (less than 5% poor). Barrios were neighborhoods where 50% or more of the residents were MA. Primary health insurers were Medicaid, Medicare, private or none. MA women were 13% less likely to be diagnosed early with NN disease (RR = 0.87), but this MA-NHW disparity was completely mediated by the main and interacting effects of health insurance. Advantages of health insurance were largest in low poverty neighborhoods among NHW women (RR = 1.20) while among MA women they were, paradoxically, largest in high poverty, MA barrios (RR = 1.45). Advantages of being privately insured were observed for all. Medicare seemed additionally instrumental for NHW women and Medicaid for MA women. These findings are consistent with the theory that more facilitative social and economic capital is available to MA women in barrios and to NHW women in more affluent neighborhoods. It is there that each respective group of women is probably best able to absorb the indirect and direct, but uncovered, costs of breast cancer screening and diagnosis.

Better colon cancer care for extremely poor Canadian women compared with American women

Extremely poor Canadian women were recently observed to be largely advantaged on most aspects of breast cancer care as compared with similarly poor, but much less adequately insured, women in the United States. This historical study systematically replicated the protective effects of single- versus multipayer health care by comparing colon cancer care among cohorts of extremely poor women in California and Ontario between 1996 and 2011. The Canadian women were again observed to have been largely advantaged. They were more likely to have received indicated surgery and chemotherapy, and their wait times for care were significantly shorter. Consequently, the Canadian women were much more likely to experience longer survival times. Regression analyses indicated that health insurance nearly completely explained the Canadian advantages. Implications for contemporary and future reforms of U.S. health care are discussed.

Effects of being uninsured or underinsured and living in extremely poor neighborhoods on colon cancer care and survival in California: historical cohort analysis, 1996-2011

Background

We examined the mediating effects of health insurance on poverty-colon cancer care and survival relationships and the moderating effects of poverty on health insurance-colon cancer care and survival relationships among women and men in California.

Methods

We analyzed registry data for 3,291 women and 3,009 men diagnosed with colon cancer between 1996 and 2000 and followed until 2011 on lymph node investigation, stage at diagnosis, surgery, chemotherapy, wait times and survival. We obtained socioeconomic data for individual residences from the 2000 census to categorize the following neighborhoods: high poverty (30% or more poor), middle poverty (5-29% poor) and low poverty (less than 5% poor). Primary health insurers were Medicaid, Medicare, private or none.

Results

Evidence of mediation was observed for women, but not for men. For women, the apparent effect of poverty disappeared in the presence of payer, and the effects of all forms of health insurance seemed strengthened. All were advantaged on 6-year survival compared to the uninsured: Medicaid (RR = 1.83), Medicare (RR = 1.92) and private (RR = 1.83). Evidence of moderation was also only observed for women. The effects of all forms of health insurance were stronger for women in low poverty neighborhoods: Medicaid (RR = 2.90), Medicare (RR = 2.91) and private (RR = 2.60). For men, only main effects of poverty and payers were observed, the advantaging effect of private insurance being largest. Across colon cancer care processes, Medicare seemed most instrumental for women, private payers for men.

Conclusions

Health insurance substantially mediates the quality of colon cancer care and poverty seems to make the effects of being uninsured or underinsured even worse, especially among women in the United States. These findings are consistent with the theory that more facilitative social and economic capital is available in more affluent neighborhoods, where women with colon cancer may be better able to absorb the indirect and direct, but uncovered, costs of care.