Advertisement

Prevalence and Correlates of Medical Financial Hardship in the USA

  • K. Robin YabroffEmail author
  • Jingxuan Zhao
  • Xuesong Han
  • Zhiyuan Zheng
Original Research

Abstract

Background

High patient out-of-pocket (OOP) spending for medical care is associated with medical debt, distress about household finances, and forgoing medical care because of cost in the USA.

Objective

To examine the national prevalence of medical financial hardship domains: (1) material conditions from increased OOP expenses (e.g., medical debt), (2) psychological responses (e.g., distress), and (3) coping behaviors (e.g., forgoing care); and factors associated with financial hardship.

Design and Participants

We identified adults aged 18–64 years (N = 68,828) and ≥ 65 years (N = 24,614) from the 2015–2017 National Health Interview Survey. Multivariable analyses of nationally representative cross-sectional survey data were stratified by age group, 18–64 years and ≥ 65 years.

Main Measures

Prevalence of material, psychological, and behavioral hardship and hardship intensity.

Key Results

Approximately 137.1 million (95% CI 132.7–141.5) adults reported any medical financial hardship in the past year. Hardship is more common for material, psychological and behavioral domains in adults aged 18–64 years (28.9%, 46.9%, and 21.2%, respectively) than in adults aged ≥ 65 years (15.3%, 28.4%, and 12.7%, respectively; all p < .001). Lower educational attainment and more health conditions were strongly associated with hardship intensity in multivariable analyses in both age groups (p < .001). In the younger group, the uninsured were more likely to report multiple domains of hardship (52.8%), compared to those with some public (26.5%) or private insurance (23.2%) (p < .001). In the older group, individuals with Medicare only were more likely to report hardship in multiple domains (17.1%) compared to those with Medicare and public (12.1%) or Medicare and private coverage (10.1%) (p < .001).

Conclusions

Medical financial hardship is common in the USA, especially in adults aged 18–64 years and those without health insurance coverage. With trends towards higher patient cost-sharing and increasing health care costs, risks of hardship may increase in the future.

KEY WORDS

out-of-pocket spending access to care medical financial hardship medical debt prescription drug nonadherence health insurance National Health Interview Survey 

Notes

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Supplementary material

11606_2019_5002_MOESM1_ESM.docx (29 kb)
ESM 1 (DOCX 28.9 KB)

References

  1. 1.
    Ubel PA, Abernethy AP, Zafar SY. Full disclosure--out-of-pocket costs as side effects. New Engl J Med 2013;369(16):1484–1486.CrossRefGoogle Scholar
  2. 2.
    Cohen RA, Kirzinger WK. Financial burden of medical care: a family perspective. NCHS Data Brief 2014. Accessed January 15, 2019.Google Scholar
  3. 3.
    Altice CK, Banegas MP, Tucker-Seeley RD, Yabroff KR. Financial Hardships Experienced by Cancer Survivors: A Systematic Review. J Natl Cancer Inst. 2017;109(2).Google Scholar
  4. 4.
    Zafar SY, McNeil RB, Thomas CM, Lathan CS, Ayanian JZ, Provenzale D. Population-based assessment of cancer survivors’ financial burden and quality of life: a prospective cohort study. J Oncol Pract 2015;11(2):145–150.CrossRefGoogle Scholar
  5. 5.
    Nipp RD, Zullig LL, Samsa G, et al. Identifying cancer patients who alter care or lifestyle due to treatment-related financial distress. Psycho-oncology. 2016;25(6):719–725.CrossRefGoogle Scholar
  6. 6.
    Carrera PM, Kantarjian HM, Blinder VS. The financial burden and distress of patients with cancer: Understanding and stepping-up action on the financial toxicity of cancer treatment. CA Cancer J Clin 2018;68(2):153–165.CrossRefGoogle Scholar
  7. 7.
    Gordon LG, Merollini KMD, Lowe A, Chan RJ. A Systematic Review of Financial Toxicity Among Cancer Survivors: We Can’t Pay the Co-Pay. Patient. 2017;10(3):295–309.CrossRefGoogle Scholar
  8. 8.
    Zheng ZHX, Guy GP Jr, Li C, Banegas MP, Ekwueme DU, Davidoff AJ, Jemal A, Yabroff KR. . Medical financial hardship among cancer survivors in the US. Cancer. 2018;in press.Google Scholar
  9. 9.
    Ramsey SD, Bansal A, Fedorenko CR, et al. Financial Insolvency as a Risk Factor for Early Mortality Among Patients With Cancer. J Clin Oncol: Off J Am Soc Clin Oncol 2016;34(9):980–986.CrossRefGoogle Scholar
  10. 10.
    de Souza JA, Yap BJ, Hlubocky FJ, et al. The development of a financial toxicity patient-reported outcome in cancer: The COST measure. Cancer. 2014;120(20):3245–3253.CrossRefGoogle Scholar
  11. 11.
    de Souza JA, Yap BJ, Wroblewski K, et al. Measuring financial toxicity as a clinically relevant patient-reported outcome: The validation of the COmprehensive Score for financial Toxicity (COST). Cancer. 2017;123(3):476–484.CrossRefGoogle Scholar
  12. 12.
    Khera N. Reporting and grading financial toxicity. J Clin Oncol: Off J Am Soc Clin Oncol. 2014;32(29):3337–3338.CrossRefGoogle Scholar
  13. 13.
    Zafar SY, Abernethy AP. Financial toxicity, Part II: how can we help with the burden of treatment-related costs? Oncology (Williston Park, NY). 2013;27(4):253–254, 256.Google Scholar
  14. 14.
    Zafar SY, Abernethy AP. Financial toxicity, Part I: a new name for a growing problem. Oncology (Williston Park, NY). 2013;27(2):80–81, 149.Google Scholar
  15. 15.
    de Souza JA, Kung S, O’Connor J, Yap BJ. Determinants of Patient-Centered Financial Stress in Patients With Locally Advanced Head and Neck Cancer. J Oncol Pract. 2017;13(4):e310-e318.CrossRefGoogle Scholar
  16. 16.
    Skalicka V, van Lenthe F, Bambra C, Krokstad S, Mackenbach J. Material, psychosocial, behavioural and biomedical factors in the explanation of relative socio-economic inequalities in mortality: evidence from the HUNT study. Int J Epidemiol. 2009;38(5):1272–1284.CrossRefGoogle Scholar
  17. 17.
    Yabroff KR, Dowling EC, Guy GP Jr., et al. Financial Hardship Associated With Cancer in the United States: Findings From a Population-Based Sample of Adult Cancer Survivors. J Clin Oncol: Off J Am Soc Clin Oncol. 2016;34(3):259–267.CrossRefGoogle Scholar
  18. 18.
    Banegas MP, Guy GP Jr., de Moor JS, et al. For Working-Age Cancer Survivors, Medical Debt And Bankruptcy Create Financial Hardships. Health Aff (Project Hope). 2016;35(1):54–61.CrossRefGoogle Scholar
  19. 19.
    Huang IC, Bhakta N, Brinkman TM, et al. Determinants and Consequences of Financial Hardship Among Adult Survivors of Childhood Cancer: A Report From the St. Jude Lifetime Cohort Study. J Natl Cancer Inst. 2018.Google Scholar
  20. 20.
    National Center for Health Statistics. National Health Interview Survey. https://www.cdc.gov/nchs/nhis/index.htm. Accessed January 15, 2019.
  21. 21.
    Guzman GG. American Community Survey Briefs. Household Income: 2016. https://www.census.gov/content/dam/Census/library/publications/2017/acs/acsbr16-02.pdf. 2017. Accessed January 15, 2019.
  22. 22.
    Gerteis J, Izrael D, Deitz D, LeRoy L, Ricciardi R, Miller T, Basu J. Multiple chronic conditions chartbook. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/mcc/mccchartbook.pdf. 2014. Accessed January 15, 2019.
  23. 23.
    Claxton G, Levitt L, Long M. Payments for cost-sharing increasing rapidly over time. https://www.healthsystemtracker.org/brief/payments-for-cost-sharing-increasing-rapidly-over-time/. 2016. Accessed January 15, 2019.
  24. 24.
    Hartman M, Martin AB, Espinosa N, Catlin A, The National Health Expenditure Accounts T. National Health Care Spending In 2016: Spending And Enrollment Growth Slow After Initial Coverage Expansions. Health Aff (Project Hope). 2018;37(1):150–160.CrossRefGoogle Scholar
  25. 25.
    Gordon LG, Beesley VL, Mihala G, Koczwara B, Lynch BM. Reduced employment and financial hardship among middle-aged individuals with colorectal cancer. Eur J Cancer Care. 2017;26(5).Google Scholar
  26. 26.
    Hanly P, Maguire R, Ceilleachair AO, Sharp L. Financial hardship associated with colorectal cancer survivorship: The role of asset depletion and debt accumulation. Psycho-oncology. 2018;27(9):2165–2171.CrossRefGoogle Scholar
  27. 27.
    Schoen C, Osborn R, Doty MM, Bishop M, Peugh J, Murukutla N. Toward higher-performance health systems: adults’ health care experiences in seven countries, 2007. Health Aff (Project Hope). 2007;26(6):w717–734.CrossRefGoogle Scholar
  28. 28.
    Schoen C, Osborn R, Squires D, Doty MM. Access, affordability, and insurance complexity are often worse in the United States compared to ten other countries. Health Aff (Project Hope). 2013;32(12):2205–2215.CrossRefGoogle Scholar
  29. 29.
    Institute of Medicine. Access to Healthcare in America. In: Millman M, ed. Washington, DC: National Academy Press; 1993.Google Scholar
  30. 30.
    Cohen RA, Zammitti EP. High-deductible Health Plans and Financial Barriers to Medical Care: Early Release of Estimates From the National Health Interview Survey, 2016. https://www.cdc.gov/nchs/data/nhis/earlyrelease/ERHDHP_Access_0617.pdf. Accessed January 15, 2019.
  31. 31.
    Cohen R, Zammitti E. High-deductible health plan enrollment among adults aged 18–64 with employment-based insurance coverage. NCHS Data Brief, no 317. Hyattsville, MD: National Center for Health Statistics. 2018.Google Scholar
  32. 32.
    Henry J Kaiser Family Foundation. Payments for Cost Sharing Increasing Rapidly Over Time. 2017; https://www.kff.org/health-costs/issue-brief/payments-for-cost-sharing-increasing-rapidly-over-time/. Accessed January 15, 2019.
  33. 33.
    Briesacher BA, Gurwitz JH, Soumerai SB. Patients at-risk for cost-related medication nonadherence: a review of the literature. J Gen Intern Med. 2007;22(6):864–871.CrossRefGoogle Scholar
  34. 34.
    Osterberg L, Blaschke T. Adherence to medication. New Engl J Med. 2005;353(5):487–497.CrossRefGoogle Scholar
  35. 35.
    Blanchard J, Madden JM, Ross-Degnan D, Gresenz CR, Soumerai SB. The relationship between emergency department use and cost-related medication nonadherence among Medicare beneficiaries. Ann Emerg Med. 2013;62(5):475–485.CrossRefGoogle Scholar
  36. 36.
    Heisler M, Choi H, Rosen AB, et al. Hospitalizations and deaths among adults with cardiovascular disease who underuse medications because of cost: a longitudinal analysis. Med Care. 2010;48(2):87–94.CrossRefGoogle Scholar
  37. 37.
    Yabroff KR, Zhao J, Zheng Z, Rai A, Han X. Medical Financial Hardship among Cancer Survivors in the United States: What Do We Know? What Do We Need to Know? Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology: 2018.Google Scholar
  38. 38.
    Mandelblatt JS, Yabroff KR, Kerner JF. Equitable access to cancer services: A review of barriers to quality care. Cancer. 1999;86(11):2378–2390.CrossRefGoogle Scholar
  39. 39.
    Paez KA., Mallery, CJ. A little knowledge is a risky thing: Wide gap in what people think they know about health insurance and what they actually know. American Institutes for Research Issue Brief. http://www.air.org/resource/little-knowledge-risky-thing-wide-gap-what-people-think-they-know-about-health-insurance. 2014. Accessed January 15, 2019.
  40. 40.
    Tipirneni R PM, Kullgren JT, Kieffer EC, Goold SD, Scherer AM. Association Between Health Insurance Literacy and Avoidance of Health Care Services Owing to Cost. JAMA Netw Open. 2018;1(7).Google Scholar
  41. 41.
    Norton M HL, Brodie M. Assessing Americans’ Familiarity With Health Insurance Terms and Concepts. https://www.kfforg/health-reform/poll-finding/assessing-americans-familiarity-with-health-insurance-terms-and-concepts/ . 2014;Accessed December 6, 2018.
  42. 42.
    Politi MC, Kaphingst KA, Kreuter M, Shacham E, Lovell MC, McBride T. Knowledge of health insurance terminology and details among the uninsured. Med Care Res Rev. 2014;71(1):85–98.CrossRefGoogle Scholar
  43. 43.
    Levitt L. Why health insurance literacy matters. Jama. 2015;313(6):555–556.CrossRefGoogle Scholar
  44. 44.
    Politi MC, Kaphingst KA, Liu JE, et al. A Randomized Trial Examining Three Strategies for Supporting Health Insurance Decisions among the Uninsured. Med Decis Making : Int J Soc Med Decis Mak. 2016;36(7):911–922.CrossRefGoogle Scholar
  45. 45.
    Zafar SY, Ubel PA, Tulsky JA, Pollak KI. Cost-related health literacy: a key component of high-quality cancer care. J Oncol Pract. 2015;11(3):171–173.CrossRefGoogle Scholar
  46. 46.
    Yabroff KR ZJ, Zheng Z, Rai A, Han X. Medical financial hardship among cancer survivors in the United States: what do we know? what do we need to know? Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology. 2018;in press.Google Scholar
  47. 47.
    Shankaran V, Leahy T, Steelquist J, et al. Pilot Feasibility Study of an Oncology Financial Navigation Program. J Oncol Pract. 2018;14(2):e122-e129.CrossRefGoogle Scholar
  48. 48.
    Zafar SY. Financial Toxicity of Cancer Care: It’s Time to Intervene. J Natl Cancer Inst. 2016;108(5).Google Scholar
  49. 49.
    Robert Wood Johnson Foundation. Costs of Care: Getting the Patient-Provider Conversation Right. https://www.rwjf.org/en/blog/2016/06/costs_of_care_getti.html. Accessed January 15, 2019.
  50. 50.
    Look KA. Value-based insurance design and medication adherence: opportunities and challenges. Am J Manag Care. 2015;21(1):e78–90.Google Scholar
  51. 51.
    Wherry LR, Miller S. Early Coverage, Access, Utilization, and Health Effects Associated With the Affordable Care Act Medicaid Expansions: A Quasi-experimental Study. Ann Intern Med. 2016;164(12):795–803.CrossRefGoogle Scholar
  52. 52.
    Miller S, Wherry LR. Health and Access to Care during the First 2 Years of the ACA Medicaid Expansions. New Engl J Med 2017;376(10):947–956.CrossRefGoogle Scholar
  53. 53.
    Antonisse L, Garfield R, Rudowitz R, Atiga S. Kaiser Family Foundation. The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review. https://www.kff.org/medicaid/issue-brief/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review-september-2017/ 2017. Accessed January 15, 2019.
  54. 54.
    Sarpatwari A, Avorn J, Kesselheim AS. State Initiatives to Control Medication Costs--Can Transparency Legislation Help? New Engl J Med 2016;374(24):2301–2304.CrossRefGoogle Scholar
  55. 55.
    National Academy for State Health Policy. State Legislative Action on Pharmaceutical Prices. https://nashp.org/state-legislative-action-on-pharmaceutical-prices/. Accessed January 15, 2019.
  56. 56.
    Protection from Surprise Bills and Emergency Services. https://www.dfs.ny.gov/consumer/hprotection.htm. Accessed January 15, 2019.
  57. 57.
    National Conference of State Legislatures. State Family and Medical Leave Laws http://www.ncsl.org/research/labor-and-employment/state-family-and-medical-leave-laws.aspx. Accessed January 15, 2019.

Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • K. Robin Yabroff
    • 1
    Email author
  • Jingxuan Zhao
    • 1
  • Xuesong Han
    • 1
  • Zhiyuan Zheng
    • 1
  1. 1.Surveillance and Health Services Research ProgramAmerican Cancer SocietyAtlantaUSA

Personalised recommendations