Strategic Financial Factors

In the United States and other countries without universal healthcare, the financial and insurance status of the patient (and family) may indeed influence access to medical care. Adolescence to young adulthood is an age range with great financial variance. Younger adolescents are usually covered by parental insurance plans. For working class families, there are programs (such as the Children's Health Insurance Plan, CHIP) that provide low-cost insurance for children up to their 19th birthday. For poor adolescents, there is Medicaid. However, there are many adolescents, although eligible, whose parents do not sign up for these programs and therefore remain uninsured - importantly, this means they continue to access services as if they are uninsurable. Furthermore, as children leave their parents' home, they often become uninsured or underin-sured. Whilst many colleges provide health services to fully enrolled students, part-time students or students who sporadically attend have limited coverage.

In the United States, young adults are the most under-insured age group, falling in the gap between parental coverage augmented by programs designed to provide universal health insurance to children (Medicaid and CHIP) and the coverage supplied by a full-time secure job [8]. Lifetime uninsured rates for those who present for care peak for females between ages 15 and 17 years (29%) and for males between ages 18 and 21 years (24%) [9]. True uninsured rates are likely to be higher, as those who do not present for care may not do so because of lack of insurance [10]. Recent data found that 33% of males and 27% of females aged 1824 years are uninsured at a given point in time [11]; another study found 31.4% uninsured for the entire previous year [12].

The hypothesis is that a lack of insurance decreases the therapeutic options for patients (access to second opinions, access to expensive treatments and medication, and choice of specialists). We know that for children under age 15 years with cancer, socioeconomic status appears to have little impact on registration with the Children's Cancer Group, suggesting that low socioeconomic status is not a barrier to access to cooperative group care and clinical trials. However, the reason the majority of 15- to 19-year-olds do not register with the pediatric oncology group is not related to socioeconomic factors, but to age [13].

There is evidence in the United States that there is a delay in the diagnosis of cancer in 15- to 30-year-olds who are under- or uninsured compared with those with private insurance [14]. A study of older adolescent and young adult patients receiving care at the University of Texas MD Anderson Cancer Center found that there was an average difference of 7 weeks in the time from first symptom to diagnosis between those with public insurance and those with private insurance, and on multivariate analysis this was more significant than any other variable (median household income, age, race, urban vs. rural location, etc.) except for tumor type [14].

Other strategic issues for adolescents include the logistics of getting to care. Although adolescents are moving developmentally toward independence from their parents, they rarely have their own stable means of transportation, limiting independent access to care. For example, a sexually active teenager notices a tes-ticular mass. He takes the initiative to see his primary care physician, who orders an ultrasound to be done at the hospital across town. He is unwilling to ask his parents to drive him to the appointment because he is afraid that the mass has something to do with his sexual activity, of which they are not aware, so he does not attend for the planned scan.

In addition, the care that is accessible may not be the most appropriate care. Although there is not a shortage of oncologists in the United States, there are 2.4 medical oncologists for every 15- to 19-year-old cancer patient, but only 0.44 pediatric oncologists. These data were calculated from the number of medical oncologists and pediatric oncologists for 15- to 19-year-old cancer patients in the United States, determined from 2006 Cancer Statistics [15], and the American Board of Internal Medicine (http:\\www. abim.org/resources/dnum.shtm) and American Board of Pediatrics (http://www.abp.org/stats/WRKFRC/ Hemo.ppt) board certification data. Furthermore, the pediatric oncologists are not evenly distributed geographically. Ironically, this means that whereas pediatric oncology patients are underserved because of their limited geographic access to care, it means that adolescents might be misserved, by the geographically available, but not necessarily appropriate care. This issue of geography then is complexly tied in with provider services and patient education and choice. The patient may not be aware that traveling further may result in more and perhaps "better" treatment options. Yet when 271 young adult cancer survivors age 14 to 23 years were asked in a United Kingdom survey, 63% reported they would be willing to travel half a day or more for their cancer treatment and 49% would go "any distance or time" to get their cancer care (personal communication, S. Davies, 2005).

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