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      Affordable Care Act and Cancer Survivors' Financial Barriers to Care: Analysis of the National Health Interview Survey, 2009-2018

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          Abstract

          PURPOSE:

          Since Affordable Care Act (ACA) implementation in 2014, studies have demonstrated gains in insurance coverage for cancer survivors < 65 years. We assessed the impact of ACA implementation on financial barriers to care by stratifying survivors at age 65 years, when individuals typically become Medicare-eligible.

          METHODS:

          We used data from respondents with cancer in the 2009-2018 National Health Interview Survey. We identified 21,954 respondents representing approximately 7.4 million survivors, who were then age-stratified at age 65 years. Survey responses regarding financial barriers to medical care and medications were analyzed, and age-stratified multivariable logistic regression modeling was performed, which evaluated the impact of ACA implementation on these measures, adjusted for demographic and socioeconomic variables.

          RESULTS:

          After multivariable logistic regression, ACA implementation was associated with higher adjusted odds of Medicaid insurance (odds ratio [95% CI] 2.02 [1.72 to 2.36]; P < .0001) and lower adjusted odds of no insurance (0.57 [0.48 to 0.68]; P < .0001). Regarding financial barriers, ACA implementation was associated with lower adjusted odds of inability to afford medications (0.68 [0.59 to 0.79]; P < .0001), inability to afford dental care (0.83 [0.73 to 0.94]; P = .004), and delaying care (0.78 [0.69 to 0.89]; P = .002) in the 18-64 years group. Similarly, ACA implementation was associated with lower adjusted odds of secondary outcomes such as delaying refills, skipping doses, and anxiety over medical bills. Similar associations were not seen in the > 65 years group.

          CONCLUSION:

          Survivor-reported measures of financial barriers in cancer survivors age 18-64 years significantly improved following ACA implementation. Similar changes were not seen in the Medicare-eligible cohort, likely because of high Medicare enrollment and few uninsured.

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          Most cited references44

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          The financial burden and distress of patients with cancer: Understanding and stepping-up action on the financial toxicity of cancer treatment.

          "Financial toxicity" has now become a familiar term used in the discussion of cancer drugs, and it is gaining traction in the literature given the high price of newer classes of therapies. However, as a phenomenon in the contemporary treatment and care of people with cancer, financial toxicity is not fully understood, with the discussion on mitigation mainly geared toward interventions at the health system level. Although important, health policy prescriptions take time before their intended results manifest, if they are implemented at all. They require corresponding strategies at the individual patient level. In this review, the authors discuss the nature of financial toxicity, defined as the objective financial burden and subjective financial distress of patients with cancer, as a result of treatments using innovative drugs and concomitant health services. They discuss coping with financial toxicity by patients and how maladaptive coping leads to poor health and nonhealth outcomes. They cover management strategies for oncologists, including having the difficult and urgent conversation about the cost and value of cancer treatment, availability of and access to resources, and assessment of financial toxicity as part of supportive care in the provision of comprehensive cancer care. CA Cancer J Clin 2018;68:153-165. © 2018 American Cancer Society.
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            Cancer survivors and unemployment: a meta-analysis and meta-regression.

            Nearly half of adult cancer survivors are younger than 65 years, but the association of cancer survivorship with employment status is unknown. To assess the association of cancer survivorship with unemployment compared with healthy controls. A systematic search of studies published between 1966 and June 2008 was conducted using MEDLINE, CINAHL, EMBASE, PsycINFO, and OSH-ROM databases. Eligible studies included adult cancer survivors and a control group, and employment as an outcome. Pooled relative risks were calculated over all studies and according to cancer type. A Bayesian meta-regression analysis was performed to assess associations of unemployment with cancer type, country of origin, average age at diagnosis, and background unemployment rate. Twenty-six articles describing 36 studies met the inclusion criteria. The analyses included 20,366 cancer survivors and 157,603 healthy control participants. Studies included 16 from the United States, 15 from Europe, and 5 from other countries. Overall, cancer survivors were more likely to be unemployed than healthy control participants (33.8% vs 15.2%; pooled relative risk [RR], 1.37; 95% confidence interval [CI], 1.21-1.55). Unemployment was higher in breast cancer survivors compared with control participants (35.6% vs 31.7%; pooled RR, 1.28; 95% CI, 1.11-1.49), as well as in survivors of gastrointestinal cancers (48.8% vs 33.4%; pooled RR, 1.44; 95% CI, 1.02-2.05), and cancers of the female reproductive organs (49.1% vs 38.3%; pooled RR, 1.28; 95% CI, 1.17-1.40). Unemployment rates were not higher for survivors of blood cancers compared with controls (30.6% vs 23.7%; pooled RR, 1.41; 95% CI, 0.95-2.09), prostate cancers (39.4% vs 27.1%; pooled RR, 1.11; 95% CI, 1.00-1.25), or testicular cancer (18.5% vs 18.1%; pooled RR, 0.94; 95% CI, 0.74-1.20). For survivors in the United States, the unemployment risk was 1.5 times higher compared with survivors in Europe (meta-RR, 1.48; 95% credibility interval, 1.15-1.95). After adjustment for diagnosis, age, and background unemployment rate, this risk disappeared (meta-RR, 1.24; 95% CI, 0.85-1.83). Cancer survivorship is associated with unemployment.
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              Measuring financial toxicity as a clinically relevant patient‐reported outcome: The validation of the COmprehensive Score for financial Toxicity (COST)

              BACKGROUND Cancer and its treatment lead to increased financial distress for patients. To the authors' knowledge, to date, no standardized patient‐reported outcome measure has been validated to assess this distress. METHODS Patients with AJCC Stage IV solid tumors receiving chemotherapy for at least 2 months were recruited. Financial toxicity was measured by the COmprehensive Score for financial Toxicity (COST) measure. The authors collected data regarding patient characteristics, clinical trial participation, health care use, willingness to discuss costs, psychological distress (Brief Profile of Mood States [POMS]), and health‐related quality of life (HRQOL) as measured by the Functional Assessment of Cancer Therapy: General (FACT‐G) and the European Organization for Research and Treatment of Cancer (EORTC) QOL questionnaires. Test‐retest reliability, internal consistency, and validity of the COST measure were assessed using standard‐scale construction techniques. Associations between the resulting factors and other variables were assessed using multivariable analyses. RESULTS A total of 375 patients with advanced cancer were approached, 233 of whom (62.1%) agreed to participate. The COST measure demonstrated high internal consistency and test‐retest reliability. Factor analyses revealed a coherent, single, latent variable (financial toxicity). COST values were found to be correlated with income (correlation coefficient [r] = 0.28; P<.001), psychosocial distress (r = ‐0.26; P<.001), and HRQOL, as measured by the FACT‐G (r = 0.42; P<.001) and by the EORTC QOL instruments (r = 0.33; P<.001). Independent factors found to be associated with financial toxicity were race (P = .04), employment status (P<.001), income (P = .003), number of inpatient admissions (P = .01), and psychological distress (P = .003). Willingness to discuss costs was not found to be associated with the degree of financial distress (P = .49). CONCLUSIONS The COST measure demonstrated reliability and validity in measuring financial toxicity. Its correlation with HRQOL indicates that financial toxicity is a clinically relevant patient‐centered outcome. Cancer 2017;123:476–484. © 2016 American Cancer Society.
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                Author and article information

                Contributors
                (View ORCID Profile)
                (View ORCID Profile)
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                Journal
                JCO Oncology Practice
                JCO Oncology Practice
                American Society of Clinical Oncology (ASCO)
                2688-1527
                2688-1535
                July 13 2021
                : OP.21.00095
                Affiliations
                [1 ]Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
                [2 ]Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
                [3 ]Rogel Cancer Center, Michigan Medicine, Ann Arbor, MI
                [4 ]Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
                [5 ]Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI
                Article
                10.1200/OP.21.00095
                34255545
                7c05b6bc-0349-4a56-aaf7-757bb9a53396
                © 2021
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