individual buyers reduce the effective premium to the point where insurance remains attractive to low-risk people (Merlis, 2005).

Relatively little is known directly of the experience of individuals with a history of cancer who lack health insurance. A recent study in California of the uninsured population’s access to specialty care found the safety net to be inadequate (Felt-Lisk et al., 2004). Nearly one-third (32 percent) of medical directors of the state’s federally qualified health centers (FQHCs) in 2002–2003 indicated that uninsured patients have difficulty obtaining oncology care “often” or “always.” Obtaining neurology, endocrinology, and allergy/immunology care were much more problematic. One-half of the FQHC medical directors reported that access to specialty care in general had gotten worse in the past 2 years. Hospitals were found to be the major source of specialty care for the uninsured. That chronic symptoms or conditions were not well managed or treated on a timely basis were among the findings from focus groups held among uninsured individuals with a range of chronic conditions requiring specialty care services. In other research, community health centers were found to be able to provide primary care and other services to most of their uninsured patients, but were limited in their ability to provide diagnostic, specialty, and behavioral health services. Uninsured patients often failed to receive additional services for which they were referred (Gusmano et al., 2002).

Cancer Survivors with Health Insurance

Cancer survivors with health insurance coverage may have problems maintaining their coverage following a cancer diagnosis. In addition, those with coverage may find it is inadequate to pay for all of the care and services they need. Sometimes, it is unclear whether an insurance policy covers recommended treatments. For example, insurers may challenge claims for interventions designed to prevent or ameliorate late effects of cancer because of interpretations of what constitutes accepted and appropriate care. In some cases, states have mandated that insurers cover survivorship-related services such as breast prostheses and lymphedema therapy. Federal law mandates coverage for reconstructive surgery and these survivorship-related services in health plans that cover mastectomy.

Maintaining health insurance coverage For cancer survivors who lose their jobs, the federal law known as COBRA mandates that they can keep the health insurance they had through their employer for 18 months.13 Some


The Consolidated Omnibus Budget Reconciliation Act of 1986 (Pub. L. No. 99–272) requires employers to offer group medical coverage to employees and their dependents who otherwise would have lost their group coverage due to qualifying events. Employers with

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