Editorial
Authors: E. Huerta
Journal: CA A Cancer Journal for Clinicians (2008)

Of all the forms of inequality, injustice in health care is the most shocking and inhumane. Martin Luther King, Jr.1 You may have seen the American Cancer Society (ACS) television ads illustrating the impact of being uninsured or underinsured when faced with a cancer diagnosis (these ads can also be viewed on the ACS Web site at http://www.cancer.org/docroot/subsite/accesstocare/index.asp). Since these ads began airing in September 2007, we have received thousands of phone calls, letters, and e-mails regarding this issue. Most have thanked us for raising public awareness of the harm resulting from limited access to health care, and some have even included accounts of their family's suffering. On the other hand, others have suggested (mistakenly so, in my opinion) that this activity was an inappropriate departure from our usual emphasis on cancer research, patient service, and public information. The mission of the ACS is “… preventing cancer, saving lives, and diminishing suffering from cancer, through research, education, advocacy, and service.” Over the years, we have been active in research, public education, and advocacy regarding tobacco use because there is strong evidence that tobacco is responsible for about one-third of all cancer deaths and contributes prominently to suffering associated with both fatal and nonfatal cases of cancer. We have also fought relentlessly for programs that make breast, cervical, and colorectal cancer screening available to low-income, underserved populations; for legislation that mandates cancer screening coverage by private and public insurance; and for Medicaid and other programs that fund cancer treatment for those who are unable to pay. Despite the gains in all of these areas, it is clear that a more comprehensive approach is needed. Hard evidence shows that people without health insurance and those with limited or intermittent coverage are less likely to get screened, more likely to get diagnosed at late stage, and less likely to survive after a cancer diagnosis. Our involvement in advocacy for health care reform is consistent with our mission and is evidence-based. It is indisputable that many lives are being lost and many families are suffering due to a system that denies access to health care for so many Americans. As clinicians, we see direct evidence of how lack of access to care impacts our patients. Virtually any clinician who treats people with cancer in the United States knows of patients who presented with advanced cancer that should have been found early, but was not. For many of these patients, cost of care and lack of access to care were the primary barriers to earlier diagnosis. This problem is not confined to Americans who have no health insurance. It impacts patients who have types of insurance that are not accepted by providers due to low reimbursement rates, those with insurance who cannot afford copayments or whose policies do not cover needed services, and is a unique barrier to those who are already burdened with medical debt. We all remember patients who died prematurely (despite expensive treatment) because they received care only sporadically in emergency departments, had no primary care provider to help with tobacco cessation or other preventive care, or because their insurance status precluded receiving the usual standard of oncology care once they were diagnosed. It is difficult enough for a patient to face a cancer diagnosis and all of the decisions and adjustments related to treatment without worrying that treatment could put themselves or their family into bankruptcy or that their treatment will be delayed because they cannot find a doctor willing to treat them. Evidence presented in this issue of CA2 documents the substantial cancer morbidity and mortality caused by inadequate access to health care in the United States. This evidence includes lower rates of screening, later stage at diagnosis, and poorer survival for several cancers, including breast and colorectal cancer, among the uninsured compared with the privately insured. The numbers in this report do not surprise me at all because I practice in a medically underserved community and continually observe how barriers to health care take a toll on my patients—medically, financially, and emotionally. Some of the current realities of health care in the United States remind me of my years of practice in my native Peru, where lack of access to quality health care was a concern throughout much of the country. Some people will dispute or ignore these statistics, perhaps because of cognitive dissonance with their rosy internal image of health care in the United States. One prevalent misconception is that only the poorest of the poor have trouble accessing health care and that even these poorest Americans can receive high-quality care (albeit with a little inconvenience) through hospital emergency departments and a patchwork of public and private safety-net programs. The truth is that there are gaping holes in our health care safety net and that most of these safety-net services are neither effective nor efficient in providing chronic-disease prevention, detection, or treatment. The truth is that our national reluctance to face these facts is condemning thousands of people to die from cancer each year and thousands more to die of other diseases. And for those who are unmoved by this shameful injustice, the data also show that for many hard-working, middle-class families, a diagnosis of cancer sets in motion a series of unfortunate events, including job loss, loss of employer-based insurance, bankruptcy, and all too often, premature death. For too many hard-working “average Americans,” paying for cancer treatment means not paying rent, mortgage (resulting in foreclosure or eviction), or utility bills, or even going hungry. Surveys have documented widespread dissatisfaction with the way health care access is currently rationed in the United States. Patients are angry, health care providers are frustrated, and businesses leaders are concerned that the rising cost of health care premiums is undermining their ability to compete in the global marketplace. The ACS is not proposing specific political solutions or policies, nor are we supporting particular candidates this November. Rather, in this election year, we are asking candidates to explain whether they believe the United States should continue to have the worst record for health care access among all industrialized Western nations. And we are asking candidates to propose specific policies intended to mitigate the misery and death caused by lack of health care access. Some political leaders will favor policies that rely largely on financial incentives to influence the behavior of individuals and businesses, others will favor public solutions, and most will recommend some combination. What is important is that American voters not permit candidates to pretend that the status quo is acceptable as health policy or even as economic policy. The American people deserve an opportunity to choose among candidates advocating a range of health care access policy proposals when they go to the polls this November.