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With more than 46 million uninsured Americans,1 it is not surprising that much of the focus in the current health care reform debate is on increasing the number of individuals with health insurance coverage. Although this is a commendable objective, it is not about numbers alone. The nation's policymakers also must consider the affordability, availability, and especially the adequacy of that coverage.

The American Cancer Society has formally adopted guiding principles to use in evaluating any health insurance reform proposal. Meaningful reform must include available, affordable, and adequate health insurance coverage without further segmenting the insurance market. These principles are predicated on a vision for the United States that, by 2015, everyone must have timely access to the full range of affordable, evidence-based health care necessary to optimize health and well-being. These policy principles, coupled with compelling research, such as the article by Halpern et al, “Insurance Status and Stage of Cancer at Diagnosis Among Women With Breast Cancer,“ in this edition of Cancer, demonstrate the urgency of pursuing fundamental nationwide policy change.2

In their study, Halpern et al observed that women who were diagnosed with breast cancer and were uninsured or enrolled in Medicaid at the time they initiated therapy were from 2.4 to 2.5 times more likely to be diagnosed at stage III or IV disease than women who were enrolled in private health insurance. Women who were diagnosed with more advanced-stage disease experienced lower survival rates, more debilitating treatment outcomes, and greater long-term treatment-related morbidity. Studies like that by Halpern et al offer even more compelling evidence for the importance of having adequate health insurance. The American Cancer Society is calling for a deeper understanding of the meaning of adequate health insurance coverage in our nation's debate about access to care. Another study presented in this edition of Cancer by Chen et al provides further evidence of this need, demonstrating that individuals with oropharyngeal cancer who are uninsured or who are enrolled in Medicaid are significantly more likely to be diagnosed with advanced disease than patients who have private insurance.3

Previous research has documented the importance of health insurance in receiving basic preventive care and timely treatment for serious medical conditions. According to a 2004 report that was released by the Institute of Medicine, nearly 18,000 deaths are attributed each year to the lack of health insurance, and the uninsured are more likely to use no health services at all.4 Furthermore, numerous studies have shown specifically that cancer patients without insurance or in public programs may not receive adequate prevention and treatment, resulting in poorer outcomes.

Breast cancer is the second leading cause of cancer mortality among women. It has been demonstrated that early detection and timely treatment are effective in improving outcomes. Research continues to prove, however, that the type and quality of coverage also predict the likelihood of achieving good outcomes. Halpern and his colleagues observed that 8% of women age <65 years with private insurance presented with stage III or IV disease; however, among uninsured women, the rate rose to18%, and it rose to 19% among women who were enrolled in Medicaid. Furthermore, results from the study by Halpern et al also indicated that there were significant disparities associated with minority racial status. Specifically, African-American and Hispanic women are more likely to present with advanced disease than Caucasian women. Using the zip code of residence as a surrogate marker for income and educational status, Halpern and his coinvestigators observed disparities among women with less education.

The study by Halpern et al. highlights the complex interactions of insurance coverage and actual delivery of high-quality care. Women who are uninsured or who are enrolled in Medicaid are less likely to receive follow-up care after an abnormal mammography screening.5, 6 Several explanations may account for this finding, and it is likely that multiple factors are interacting simultaneously. For example, some of the women may have been uninsured and may have been enrolled in Medicaid retroactively, after they were diagnosed with breast cancer, through the National Breast and Cervical Cancer Screening Program. More important, both uninsured individuals and individuals who are insured by Medicaid are less likely to have a source of primary care. Women without health insurance face great difficulty in obtaining or maintaining a regular health care provider, and the eligibility limits and structure of benefits and payments under Medicaid make it more difficult for women to have a regular provider.7 A similar pattern-of-care utilization was observed in the study by Halpern et al. In fact, having a usual primary care clinician, a trusted source of care, also known as a medical home, is a strong predictor of improved preventive care delivery.8 A primary care medical home plays a vital role in reducing cancer mortality. Individuals who have a regular source of primary care are both more likely to be up to date with cancer screening and more likely to receive timely follow-up and evaluation for abnormal findings on an initial screen.9–11 To define insurance coverage as adequate, access to primary care clinicians must be ensured.

The work of the American Cancer Society's national call center shows us the real-life urgency of the problems. The center specialists are trained to help cancer patients and their caregivers who call with finance and insurance problems. Unfortunately, there are no options to address the needs of 30% of the callers. Of those who had options, 7 of 10 found that the options were either unaffordable or inadequate for their medical needs. Our inability to help these individuals obtain and maintain affordable coverage is tragic. The stories of those with inadequate insurance should add another dimension to the health care reform debates. We are least able to assist those individuals who have insurance but who cannot access the services they need because the benefits are not covered, they have reached the limit of the benefits under their plan, or they can no longer pay their share of the cost of services. Clearly, the issues of adequacy, availability, and affordability of coverage are serious problems that must be addressed collectively as we work to fix what is wrong with our health care system.

The United States' health care crisis has created an environment that is receptive to fundamental change. The studies by Halpern et al. and Chen et al. help to illustrate that an exclusive focus on the uninsured, although it may be fundamental, is not sufficient.2, 3 Adequacy of coverage and availability of appropriate health care services are equally vital. For example, 1 state recently proposed a new health insurance plan intended to expand coverage for currently uninsured, low-income workers. The cost of coverage under the new program is ≈$1800 per year, a modest cost by today's insurance standards. Nevertheless, a more detailed evaluation of the proposal reveals that the plan would fall far short of providing life-saving health care services. The benefits include a $10,000 per year limit on hospital care and a total annual benefit of $25,000. These limits are insufficient to cover a serious health condition, such as cancer. What would become of a patient with this coverage who still is receiving treatment when the limits are met? We have to contemplate this question more openly and fully in considering health care reform.

The American Cancer Society, along with our sister advocacy organization, the American Cancer Society Cancer Action Network, is dedicated to ensuring that primary care, prevention, early detection, and quality care are available to all. Achieving these goals demands health care reform. Framing the health care debate in a way that makes sense for cancer patients, survivors, their caregivers, and the general public will provide a standard by which proposals for reform can be judged. It is time to get this right. Effective solutions to our current crisis must address adequacy and affordability in addition to availability of health care insurance for all.

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