Catastrophic health expenditures, insurance churn, and non-employment among gynecologic cancer patients in the United States

BACKGROUND In recent years, there has been growing recognition of the financial burden of severe illness, including associations with higher rates of non-employment, uninsurance and catastrophic out-of-pocket health spending. Gynecologic cancer patients often require expensive and prolonged treatments, potentially disrupting employment and insurance coverage access, and putting patients and their families at risk for catastrophic health expenditures. OBJECTIVE To describe the prevalence of insurance churn, non-employment, and catastrophic health expenditures among non-elderly gynecologic cancer patients in the United States, to compare within subgroups and to other populations, and to assess for changes associated with the Affordable Care Act. STUDY DESIGN We identified respondents ages 18-64 from the Medical Expenditure Panel Survey, 2006-2017, who reported care related to gynecologic cancer in a given year, as well as a propensity-matched cohort of patients without cancer, and patients with cancers of other sites, as comparison groups. We applied survey weights to extrapolate to the US population, and we described patterns of insurance churn (any uninsurance, insurance loss/change), catastrophic health expenditures (>10% annual family income), and non-employment. Characteristics and outcomes between groups were compared with the Adjusted Wald test. RESULTS We identified 683 respondents reporting care related to a gynecologic cancer diagnosis from 2006-2017, representing an estimated annual population of 532,400 (95% CI 462,000-502,700) patients. Over 64% of patients reported at least one of the three primary negative outcomes of any uninsurance, part-year non-employment, and catastrophic health expenditures, with 22.4% reporting at least two of the three. Catastrophic health spending was uncommon without non-employment or uninsurance reported during that year (1.2% of population). Relative to other cancer patients, the gynecologic cancer population was younger, more likely with low education and low family income (≤250% Federal Poverty Level). They reported higher annual risks of insurance loss (8.8% vs. 4.8%; p=0.03), any uninsurance (22.6% vs. 14.0%; p=0.002), and part-year non-employment (55.3% vs. 44.6%; p=0.005), but similar risks of catastrophic spending (12.6% vs. 12.2%, p=0.84). Gynecologic cancer patients from low-income families faced starkly higher risk of catastrophic expenditures relative to those of higher incomes (24.4% vs. 2.9%, p<0.001). Among the low-income, Medicaid coverage was associated with lower risk of catastrophic spending relative to private insurance. After Affordable Care Act implementation, we observed reductions in risk of uninsurance, but no significant changes in risk of catastrophic spending among gynecologic cancer patients. CONCLUSION Gynecologic cancer patients face high risks of uninsurance, non-employment, and catastrophic health expenditures, particularly among patients from low-income families. Catastrophic spending was uncommon in absence of either non-employment or uninsurance in a given year.