Medical financial hardship linked to increased mortality risk among cancer survivors
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Long-term medical financial hardship after active cancer treatment has become an important topic in survivorship and has been evaluated in several studies.
However, few studies have focused on the extent to which financial hardship affects health outcomes — including survival — among cancer survivors.
“One study conducted in Washington state evaluated the association between bankruptcy declaration and mortality risk,” Robin Yabroff, PhD, MBA, scientific vice president of health services research at American Cancer Society, said in an interview with Healio. “However, it was only conducted in a single state. Our study uses nationally representative data.”
Yabroff and colleagues examined health outcomes associated with financial hardship among cancer survivors using data from the 1997-2014 National Health Interview Survey (NHIS) and NHIS Linked Mortality Files through 2015. The researchers identified about 25,000 survivors aged 18 to 64 years (n = 14,917) and 65 to 79 years (n = 10,391). They estimated mortality risk by age group, controlling for the effects of sociodemographic factors, and added medical insurance coverage sequentially to multivariable models.
Results showed a higher adjusted mortality risk among survivors with vs. without hardship in the younger (HR = 1.17; 95% CI, 1.04-1.3) and older (HR = 1.14; 95% CI, 1.02-1.28) age groups. Adjustment for health insurance coverage attenuated the association among the younger group (HR = 1.09; 95% CI, 0.97-1.24) but not among the older group (HR = 1.15; 95% CI, 1.02-1.29).
Yabroff spoke with Healio about the results of the study and discussed potential ways to reduce financial hardship in cancer survivors.
Healio: Why did you analyze the data on survivors based on age?
Yabroff: We looked at cancer survivors in two age groups based on age-eligibility for Medicare. Most working-age people receive health insurance coverage through their employers, and employment patterns are quite different between adults aged 18 to 64 years and those aged 65 years and older. So, that was the main rationale for looking at those two groups separately.
Healio: What did you find?
Yabroff: We found increased mortality risk in both age groups. However, when we later added information about health insurance coverage, the magnitude of the association for the younger group decreased and was no longer statistically significant. So, health insurance appears to play an important role in the association of financial hardship and mortality in that younger age group.
In the group that was age-eligible for Medicare, the inclusion of health insurance coverage type didn’t make much of a difference. This suggests that Medicare can provide some protective effect. That’s also supported by the fact that in our study, about 30% of people aged 18 to 64 years reported delaying or forgoing care because they couldn’t afford it in the past 12 months, compared with about 11% in the older population.
Healio: Younger individuals might also need to take extended time away from work, which might jeopardize their employer-based insurance. Is this an issue?
Yabroff: This isn’t something we could examine specifically but is something we worry about in general. This can reduce their income if they don’t have paid sick leave, and even those with paid sick leave might use it all. So, they could have not only reduced income, but could also lose access to their employer or sponsored health insurance if they continue to have challenges with working.
Healio: What can be done to improve these financial hardships and their potential health consequences?
Yabroff: There is no single solution for the two age groups. There’s the issue related to comprehensive health insurance coverage for the younger population. Thirty-one percent of the survivors who reported financial hardship or having to delay or forego care did not have insurance. So, having comprehensive health insurance coverage is very important.
In terms of Medicare, I support things like having out-of-pocket caps for Medicare Part D, which is the pharmacy benefit, and considering caps for Medicare Part B, which is for outpatient services. Those would help cancer survivors who are Medicare beneficiaries. Even though health insurance coverage did not play as big of a role in that older population, they are still vulnerable to financial hardship.
We are also looking into future studies evaluating different types of health insurance coverage. High-deductible health insurance plans are increasingly common in employer-based coverage. We want to try to understand what having a high-deductible plan might mean for someone with cancer or someone who wants to delay care until they have met their deductible. Patients with cancer are receiving more treatments, and they’re receiving those treatments for longer periods of time. Importantly, many patients with treatment receive other types of care — they may have imaging or seek care in the hospital. So, it’s not just the cancer therapy itself. It’s a cumulative effect.
Healio: What’s next in terms of your research in this area?
Yabroff: We have a number of ongoing studies. One thing I am always interested in is how oncologists and other health care providers talk with their patients about expected out-of-pocket costs and how that might influence treatment recommendations.
Another broad research area is related to health insurance policy and the effects of the Affordable Care Act. I am interested in what it means for patients with cancer who live in Medicaid expansion states, where they may be newly eligible for health insurance coverage compared with patients living in states that chose not to expand. How does that impact financial hardship?
We are also thinking about how the pandemic has affected access to cancer screening, receipt of timely treatment and the conditions of treatment, and how financial hardship may have changed during the pandemic. Those are the sorts of things we can evaluate once those data become available.
For more information:
Robin Yabroff, PhD, MBA, can be reached at National Cancer Institute, 3380 Chastain Meadows Parkway, Suite 200, Kennesaw, GA 30144; email: robin.yabroff@cancer.org.
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