"The role of public insurance programs for early cancer detection and access to care among cancer survivors"

Committee

Lindsay Sabik, Department of Health Policy and Management, University of Pittsburgh School of Public Health 

Evan S. Cole, Department of Health Policy and Management, University of Pittsburgh School of Public Health

Howard Degenholtz, Department of Health Policy and Management, University of Pittsburgh School of Public Health

Eric Roberts, University of Pennsylvania, Perelman School of Medicine and Leonard Davis Institute of Health Economics

Bruce Jacobs, Research Chief, Division of Health Services, Department of Urology, University of Pittsburgh School of Medicine

Abstract:

Population diagnosed with cancer is steadily growing in the US, prompting conversations about how to best ensure optimal quality of cancer care. Medicare and Medicaid—two premier public insurance programs—play a critical role in providing health insurance coverage to this population. Medicare is the largest payer of health services for cancer patients and survivors, most of whom are seniors. Medicaid is a growing source of coverage for younger adults with low income or disabilities, who historically have faced adverse cancer outcomes due to experiences of socioeconomic hardship. Considering the rising incidence and burden of cancer, rigorous policy analysis to inform effective cancer prevention and control in public programs is crucial.

Thus, this dissertation aims to investigate elements of the Medicare and Medicaid program administration that are yet to be extensively studied in the context of cancer prevention and control. In Aim 1, I examine eligibility for Medicare at age 65 and its implication for older adult cancer survivors' healthcare access and affordability. Using a regression discontinuity design among a nationally representative sample of cancer survivors, I find that attaining Medicare eligibility is associated with significant reduction, but not elimination, of cost-related barriers to care. Aim 2 assesses the impact of managed care in Medicaid, a predominant mode of administering Medicaid services through private insurance carriers, on early cancer detection. I exploit the recent expansion of mandatory managed care in Pennsylvania's Medicaid as a natural experiment and find that this expansion was associated with improvement in early detection. In Aim 3, I evaluate disparities in cancer screening associated with experiences of homelessness and housing insecurity, an increasing focus of Medicaid programs seeking to address nonmedical determinants of health. Using a novel linkage of Pennsylvania's administrative Medicaid and housing services records, I find that women adult Medicaid beneficiaries experiencing or at risk of homelessness (as indicated by receipt of housing-related support and services) are significantly less likely to receive guideline-recommended mammograms.

These results point to several avenues for reforming Medicare and Medicaid programs for effective cancer prevention and control. Aim 1 reaffirms the importance of Medicare as a coverage source for cancer survivors and suggests that expanding its eligibility and cost protection within Medicare can further lessen the financial burden of care among older cancer survivors. Aim 2 illustrates the potential for a managed care program to address the high incidence of advanced-stage cancer, a key driver of adverse outcomes in Medicaid, though designs and details of managed care matter in facilitating early detection. Aim 3 demonstrates that optimal cancer prevention will require greater efforts among public programs to address vulnerability to homelessness, housing insecurity, and other health-related social needs.