Journal of the National Cancer Institute Advance Access originally published online on November 13, 2007
JNCI Journal of the National Cancer Institute 2007 99(22):1660-1663; doi:10.1093/jnci/djm244
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© Oxford University Press 2007.
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Cancer, Medical Groups Campaign for Uninsured
While watching your favorite prime-time TV show, you may have seen a new message from the American Cancer Society. "This is what a health care crisis looks like to the American Cancer Society," a narrator says, as images of cancer patients flash on screen. These are the "people with cancer but without insurance; countless others with insurance, just not enough to cover something as devastating as cancer."
This commercial is part of the cancer society's nationwide media campaign aimed at educating the nation about the need for universal health insurance. ACS has dedicated their entire advertising budget of $15 million per year to the campaign. "We set a goal to make health care the leading domestic issue in the coming election season," said Richard Wender, M.D., national volunteer president of the organization.
To meet this goal, ACS is spreading the word with ads on network and cable television, as well as in major print publications and online. ACS is not the only group to take up the cause. The American Medical Association has launched a similar campaign to heighten voters’ awareness of America's health insurance problem.
"What was happening is everyone knows something has to be done, but there is no solution that is being seriously talked about," said Nancy Nielsen, M.D., Ph.D., president-elect of the AMA. The AMA intends to jumpstart the conversation with its own media blitz with TV, print, and online ads, as well as roadside and bus stop billboards in Washington, D.C., and the early primary election states of Iowa, New Hampshire, and South Carolina.
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It is no coincidence that these two major medical organizations have independently decided to tackle this issue. The health care crisis in the United States has reached a boiling point for much of the electorate. Nearly 47 million Americans are uninsured, a figure that is up by more than 2 million since 2005. Health care is already the leading domestic issue for voters in the upcoming election, said Richard Brown, Ph.D., director of the UCLA Center for Health Policy Research. By putting the weight of their prominent medical associations behind the issue, "[ACS and the AMA] are now part of a very broad movement in this country to expand health insurance."
Increasing the number of insured Americans is critical, Wender said, if ACS is to reach its goals set in the 1990s to reduce cancer deaths by 50% and cancer incidence by 25% by the year 2015. As it stands now, ACS is on track to reach only half of its mortality goal—reducing cancer deaths by 25% rather than 50%. "Unless we improve and overcome major barriers to access to care, we would not be able to achieve our goal. Thus we must ... dedicate our resources to helping to improve access [to health care]," he said.
Research supports the idea that ACS can help reach its goals by advocating for universal health insurance—in general, cancer patients with insurance fare better. Two studies in the June issue of Cancer conducted by researchers at ACS found that breast cancer patients without insurance or on Medicaid were about 2.5 times more likely to be diagnosed with advanced-stage cancer than early-stage cancer, compared with insured patients. Similarly, a study of patients with oropharyngeal cancer, a type of throat cancer, showed that the odds of being diagnosed with advanced-stage cancer were 37% greater among uninsured patients and 31% greater among Medicaid patients than patients with private insurance. (The researchers suspect that many Medicaid patients were uninsured before their diagnosis but enrolled in Medicaid upon learning that they had cancer.)
Patients with advanced cancer must undergo more invasive treatment procedures that come with more harmful side effects, a higher price tag, and often worse outcomes. For example, early-stage oropharyngeal cancer is usually treated with surgery or radiation, which at that stage has few side effects. But by the time a patient's cancer reaches stage III or IV, he needs a combination of chemotherapy and radiation that involves serious risks and potential complications, such as difficulty swallowing or speaking normally, said Amy Chen, M.D., a head and neck cancer surgeon at Emory University in Atlanta and the lead author on one of the Cancer reports. "I think it's very important for ACS to stay evidence based," said Chen, who is also a health services researcher at the cancer society. "These papers formulate the backbone of the evidence to show that, yes, there is an issue with insurance."
The strength of the campaigns lies in this basis of hard evidence, said Thomas Oliver, Ph.D., professor of medicine and public health at the University of Wisconsin. "The thing that the cancer society, in particular, can ground its campaign in is the science linking whether or not you have health insurance coverage with health outcomes, and the adequacy of health insurance coverage."
The problem of underinsurance has also gained a more prominent role in these campaigns. Simply having insurance is not enough, said John Seffrin, Ph.D., chief executive officer of ACS, at a press conference held in September in Washington, D.C. "For thousands of the underinsured, cancer is a double tragedy—a life-threatening disease coupled with an intolerable financial burden," he said.
When faced with a cancer diagnosis or other serious illness, many patients find that their insurance won’t cover all their medical expenses. "This is where both the cancer society and the AMA have a lot of self-interest, so to speak. ... It's in ensuring that the research and development of new technologies are going to be paid for by insurance companies. It will do no good to do research and development if treatments cost over the amounts that are allowed by insurance companies," Oliver said.
The financial burden of cancer can be staggering, even for patients who have insurance. In a survey of cancer patients conducted by the Kaiser Family Foundation, Harvard University, and USA Today, a quarter of patients said that they used up all or most of their savings during their cancer treatment, and about 10% said that they could not pay for basic necessities such as food or housing. Among the uninsured, that figure rose to more than 40%. The quality of their cancer treatment was also affected. One in 12 patients postponed or decided against a cancer treatment because of the cost, while more than one in four uninsured patients reported making that choice.
The two medical groups believe that they can succeed by forcing the issue onto the political agenda. "Our goal is to elevate the national discussion and debate around the need to fix a very broken health care system in America," Seffrin said. "We want to create an environment in which the new president will be compelled to act."
While ACS says it is not endorsing any one candidate's health care strategy, its ideal plan will offer every American insurance that embraces ACS’ four A's of health care reform: adequate, affordable, available, and administratively simple. The AMA, on the other hand, is offering its own plan for insuring the nation: a system that builds on the current health care system and includes subsidies for the poor and the ability to choose one's own health plan. "We are very much concerned that Americans need choice," said Nielsen of the AMA. "We think that if they have the choice of their health insurance, then that will help promote market reforms. Health insurers will compete on quality and on price. Right now, Americans don’t have choice."
But, she said, the AMA is open to considering other options. "We’re asking the American people to join us in demanding of candidates that they have a plan. If they don’t like our plan, what's their plan?" The AMA will expand its campaign nationwide next year and continue efforts to rally voters around the issue of the uninsured. "Our goal is that by 2009 there will be legislation that will begin to cover all Americans," Nielsen said.
Of course, insurance is not a panacea for the nation's health care problems. While mortality rates, especially for treatable cancers like colon or breast cancer, are much lower in countries with universal access to health care, such as the Scandinavian countries, said Otis Brawley, M.D., chief medical officer at ACS, " ... universal access doesn’t take care of all the disparities between the poor and wealthy. It just decreases the disparities." But these disparities are much more difficult to address if the disparities between insured and uninsured patients are ignored.
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