Background

In recent years, there has been growing recognition of the financial burden of severe illness, including associations with higher rates of nonemployment, uninsurance, and catastrophic out-of-pocket health spending. Patients with gynecologic cancer 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

This study aimed to describe the prevalence of insurance churn, nonemployment, and catastrophic health expenditures among nonelderly patients with gynecologic cancer in the United States, to compare within subgroups and to other populations and assess for changes associated with the Affordable Care Act.

Study Design

We identified respondents aged 18 to 64 years from the Medical Expenditure Panel Survey, 2006 to 2017, who reported care related to gynecologic cancer in a given year, and 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 or insurance loss or change), catastrophic health expenditures (>10% annual family income), and nonemployment. 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 to 2017, representing an estimated annual population of 532,400 patients (95% confidence interval, 462,000–502,700). More than 64% of patients reported at least 1 of 3 primary negative outcomes of any uninsurance, part-year nonemployment, and catastrophic health expenditures, with 22.4% reporting at least 2 of 3 outcomes. Catastrophic health spending was uncommon without nonemployment or uninsurance reported during that year (1.2% of the population). Compared with patients with other cancers, patients with gynecologic cancer were younger and 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=.03), any uninsurance (22.6% vs 14.0%; P=.002), and part-year nonemployment (55.3% vs 44.6%; P=.005) but similar risks of catastrophic spending (12.6% vs 12.2%; P=.84). Patients with gynecologic cancer from low-income families faced a higher risk of catastrophic expenditures than those of higher icomes (24.4% vs 2.9%; P<.001). Among the patients from low-income families, Medicaid coverage was associated with a lower risk of catastrophic spending than private insurance. After the Affordable Care Act implementation, we observed reductions in the risk of uninsurance, but there was no significant change in the risk of catastrophic spending among patients with gynecologic cancer.

Conclusion

Patients with gynecologic cancer faced high risks of uninsurance, nonemployment, and catastrophic health expenditures, particularly among patients from low-income families. Catastrophic spending was uncommon in the absence of either nonemployment or uninsurance in a given year.

中文翻译：

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美国妇科癌症患者的灾难性医疗支出、保险流失和失业

背景

近年来，人们越来越认识到严重疾病的经济负担，包括与较高的失业率、无保险率和灾难性的自付费用有关。妇科癌症患者通常需要昂贵且长期的治疗，这可能会扰乱就业和保险覆盖范围，并使患者及其家人面临灾难性医疗支出的风险。

客观的

本研究旨在描述美国非老年妇科癌症患者中保险流失、失业和灾难性医疗支出的发生率，以在亚组内和与其他人群进行比较，并评估与《平价医疗法案》相关的变化。

学习规划

我们从 2006 年至 2017 年的医疗支出小组调查中确定了年龄在 18 至 64 岁之间的受访者，他们在给定年份报告了与妇科癌症相关的护理，以及未患癌症的患者和其他部位的癌症患者的倾向匹配队列，作为对照组。我们应用调查权重来推断美国人口，并描述了保险流失（任何未保险或保险损失或变化）、灾难性医疗支出（> 10% 的家庭年收入）和失业的模式。将各组间的特征和结果与调整后的 Wald 检验进行比较。

结果

我们确定了 683 名受访者报告了 2006 年至 2017 年与妇科癌症诊断相关的护理，估计每年有 532,400 名患者（95% 置信区间，462,000–502,700）。超过 64% 的患者报告了任何未保险、部分年度失业和灾难性医疗支出的 3 种主要负面结果中的至少 1 种，22.4% 的患者报告了 3 种结果中的至少 2 种。灾难性的医疗支出在当年没有失业或未保险的情况下并不常见（占人口的 1.2%）。与其他癌症患者相比，妇科癌症患者更年轻，更有可能受教育程度低和家庭收入低（≤250% 的联邦贫困线）。他们报告了更高的年度保险损失风险（8.8% 对 4.8%；P=.03）、任何未保险（22.6% 对 14.0%；P =.002）和部分年度非就业（55.3% 对 44.6%；P =.005），但灾难性支出的风险相似（12.6% 对 12.2%；P =.84）。来自低收入家庭的妇科癌症患者比高收入家庭的妇科癌症患者面临更高的灾难性支出风险（24.4% 对 2.9%；P <.001）。在来自低收入家庭的患者中，与私人保险相比，医疗补助覆盖范围与灾难性支出的风险较低有关。《平价医疗法案》实施后，我们观察到未投保的风险有所降低，但妇科癌症患者的灾难性支出风险没有显着变化。

结论

妇科癌症患者面临没有保险、失业和灾难性医疗支出的高风险，尤其是来自低收入家庭的患者。在特定年份没有非就业或无保险的情况下，灾难性支出并不常见。