Gaps in Health Insurance Coverage: How do they affect cancer screening?

Authors: Muthukrishnan M, Arnold LD, James AS

Category: Cancer Health Disparities, Cancer Health Disparities
Conference Year: 2018

Abstract Body:
Insurance instability is defined as a gap or change in health insurance coverage. Although research historically treats insurance status as a dichotomous variable (insured/uninsured), many low-income people cycle on and off insurance. Thus, longitudinal studies that treat insurance as a constant variable may oversimplify the association between insurance status and health behaviors/outcomes. The goal of this analysis is to examine insurance instability over a 12-month period and characterize the effect of this instability on colorectal cancer (CRC) screening. Eleven federally qualified health centers participated in a cluster-randomized trial to promote CRC screening. Surveys assessed insurance status and CRC screening at baseline (n=483), 6-months, and 12-months. At baseline, 71.6% (346/483) were insured. Only participants who completed the 12-month follow-up were included in this analysis (n=273). By the 12-month follow-up, 16.1% (n=44) reported insurance instability. One-quarter of those had two status changes. Overall, 65.6% reported up-to-date CRC screening at 12 months (vs. 56.0% at baseline). Those with insurance instability were less likely to have CRC screening: ever screened (59.1% vs. 75.5%) or up-to-date (50.0% vs. 68.6%). Main reasons for lost insurance coverage included: Loss or change of job (n=23), too high costs (n=16), or never having insurance (n=21). Compared with those with continuous insurance coverage, participants with insurance instability are less likely to receive CRC screening. While we are limited by our small sample size when the data is broken down, we do know that insurance instability affects healthcare utilization. Studies that consider insurance status must focus not just on a point in time (e.g. start of the study) but also on stability of coverage over time. Individuals with insurance changes should be considered part of a vulnerable population, as this instability can affect their access to health services in ways beyond traditional barriers, such as transportation and availability of care. For this reason, it is important to be aware of insurance instability when working with patients, particularly those at FQHCs, to provide preventive and clinical services.

Keywords: Health disparities, insurance coverage, colorectal cancer screening