Transcript:

Patricia Santos, MD: My name is Patricia Santos. I am a rising fifth year resident in radiation oncology, Memorial Sloan Kettering Cancer Center.

Can you give some background about your study and what prompted you to undertake it?

Dr Santos: A lot of the work that I do at Sloan Kettering geared towards health services and health policy focuses on health care access and utilization in underserved and marginalized populations. I have a particular personal interest in immigrants because I am an immigrant myself and I'm a child of immigrants. So from a personal standpoint, studying that population's really meaningful to me. I'm also a lifelong New Yorker, and New York, as you know, is a city of immigrants. So I think for those reasons, I've always been interested in what health care looks like and what health care issues look like in this population, and really trying to bring that topic from the fringes really to the forefront.

This is a first step towards that goal. What we wanted to do was really understand what the health care barriers were in the immigrant population, which is a population that even though is booming in terms of size and importance in the United States as a whole, and will continue to do so, is very understudied in cancer. And that's concerning because two of the largest immigrant populations in the United States, Asian Americans, and Hispanic and Latino Americans, the leading cause of death is cancer for both of those populations.

So it's going to be increasingly important for us to study cancer care and disease burden in these populations. So this study was an opportunity for us to look at cancer survivors and look at what barriers immigrants and foreign-born citizens face in terms of accessing health care from an insurance standpoint, from a utilization standpoint, and also from a social determinants of health standpoint.

Can you briefly describe how the study was conducted?

Dr Santos: What we did was we took the National Health Interview Survey and we looked at the years 2019 to 2022. We looked at all adult cancer survivors over the age of 18, and we separated it into three groups based on nativity and citizenship. So US citizens, foreign-born citizens, and non-citizens. Then what we did was we looked at three big classes of outcomes. So we looked at insurance status, looking at rates of private insurance, Medicaid, and insurance. We looked at health care access or utilization. So we were looking at urgent care, ER, and inpatient admissions over the last 12 months based on survey-based responses.
And then we also looked at delays to care. And then lastly, we looked at social determinants of health, with a specific interest in financial hardship and affordability. We also looked at food insecurity and also the need for housing assistance as well in this study.

What were the key findings of your study?

Dr Santos: The key findings of our study were as follows. So we found that non-citizens were three times as likely to be uninsured compared to US citizens. We also found that foreign born citizens were two times as likely to be on Medicaid, speaking to the importance of this program as a form of public health insurance coverage for this vulnerable group. We also found that in terms of social determinants of health, that financial hardship was 1.5 times more common among both foreign born citizens as well as non-citizens. We also saw higher rates for the need of housing assistance as well as food insecurity. And we found that although food insecurity was not a significant factor on our regression analysis, it was still 33% in the non-citizen group and about 20% in the foreign born citizen group compared to about 11% only in the US citizens.

Speaking to the fact that this is probably a big effect, but we're just not seeing it given the small numbers in our study. We only had about 129 patients in the non-citizen arm. We believe that with larger numbers and with more study years, this effect would actually be more robust. But I think the main point here is that even though we have small numbers across multiple study years, the fact that multiple findings were significant even on adjusted analysis speaks to how robust these findings actually are.

And then the last thing that we found, which actually we were surprised about, but then when you think about it, really isn't that surprising at all, is that health care utilization actually wasn't higher by citizenship or nativity. So foreign born citizens and non-citizens were not more likely to use the health care system in terms of ER visits, inpatient admissions, or urgent care visits.

And this was true even on adjusted analysis. And I think this speaks to the point and against the primary narrative that we hear that if we were to give access to health care and if we were to give access to health insurance among immigrants or naturalized citizens and make health care more accessible to these groups, that they would use the health care system more. They would overburden the health care system. But what we're finding from this study is that that's just simply not the case. That even when you account for insurance status and you control for insurance status here, you still don't see that kind of difference there. So I think it directly speaks against that narrative, and I think it's a really key and important finding in our study.

Looking ahead, what potential impact do you hope your findings will have on increasing affordable access to health care?

Dr Santos: I think that this is a important first step into really understanding what health care utilization looks like among immigrant cancer survivors in the United States. And I think that it'll provide necessary data, hopefully in support of policies that will allow for immigrants of all statuses, whether you're undocumented, you're a legal permanent, or you're a lawfully present resident, or you are a naturalized citizen, that they would make avenues to accessing public health insurance on both the federal and state level much more accessible and easy, especially for cancer survivors for whom early diagnosis of recurrence is key and durable access to care during survivorship is absolutely necessary in order to have long and healthy lives.

What future studies would you like to see on health care access and utilization?

Dr Santos: I think that one of the important next steps that we're going to be doing, and this is going to be supported by the Conquer Cancer Foundation as part of my Young Investigator Award, I'm very thankful for that, is we're going to be looking at a specific, very interesting type of health insurance called emergency Medicaid, which is a federally funded but state run program, which provides coverage for health care in the event of emergency for all individuals who are income eligible for Medicaid, otherwise, apart from their immigration status.

And I think that this form of health insurance is a really important way in which undocumented immigrants in particular are able to access cancer care, particularly in the state of New York, where emergency Medicaid actually does provide coverage for chemotherapy and radiation. And this is a very unique aspect of this policy, and I think it'd be really interesting to see what the cancer and disease burden looks like in this population, the emergency Medicaid population of New York, what health care utilization looks like here and what expenditures look like.

And I think this would give us a good model for the rest of the country to see what things are working, what isn't working, because emergency Medicaid varies so much across states. So looking at New York as a model to begin with, to sort of either build on their policies or create new ones to provide better access to public health insurance will be an important first step, and that's the next thing that we're going to be doing moving forward.