Cancer survivorship, health insurance, and employment transitions among older workers

Risk Factors for Cost-Related Delays to Medical Care Among Lymphoma Patients: A 22-Year Analysis of a Nationally Representative Sample

BACKGROUND

An estimated 85,000 cases of lymphoma (Hodgkin and non-Hodgkin lymphoma) were diagnosed in the United States in 2020. Financial insecurity is known to negatively impact health outcomes. In 2021, as Americans continue to file for unemployment at rates far above pre-COVID-19 pandemic peak levels, there is a persistent need to address the economic burden of diagnoses and threat of financial stressors and its related conditions, which are already known to cause substantial economic burden.

PATIENTS AND METHODS

Data were obtained from the National Health Interview Survey (NHIS), a cross-sectional survey conducted annually by the National Center for Health Statistics. Two questions were asked of patients to identify potential risk factors of financial insecurity regarding patients' ability to pay medical bills. NHIS respondents between the years 1997 and 2018 self-reporting a history of lymphoma diagnoses was included in the analysis.

RESULTS

Among over 2 million respondents to the NHIS between 1997 and 2018, 1619 individuals reported a history of lymphoma; 9.95% reported delaying medical care due to cost within the previous 12 months; and 6.52% reported not being able to afford medical care in the previous 12 months. Among the subgroups that had the highest risk of delaying medical care were patients between the ages of 25 and 64 years and the uninsured.

CONCLUSION

Financial burdens impede patients' abilities to access and adhere to care, which can contribute to poorer health outcomes. As financially insecure patients continue to present with lymphoma diagnoses, it is vital for practicing hematologists to understand the links among health care, financial insecurity, and demographic risk factors in order to devise and implement appropriate interventions.

Progress in Cancer Control in Maryland: 1985-2015

PURPOSE

Maryland historically had a high cancer burden, which prompted the implementation of aggressive cancer control strategies. We examined the status of cancer in Maryland and work under the current and previous editions of the MD Comprehensive Cancer Control Plan.

METHODS

We examined the prevalence of cancer mortality, cancer incidence, and cancer-related behaviors in Maryland and the United States from 1985 to 2015 using publicly available data in the US Cancer Control PLANET, CDC WONDER, and Behavioral Risk Factor Surveillance System portals. We estimated the average annual cancer deaths avoided by triangulation.

RESULTS

In 1983-1987, Maryland had the highest age-adjusted cancer mortality rate of all 50 states, second only to Washington, District of Columbia. Today (2011-2015), Maryland's age-adjusted cancer mortality rate ranks 31st. Overall cancer mortality rates have declined 1.9% annually from 1990 to 2015, avoiding nearly 60 000 deaths over 3 decades. While the prevalence of healthy cancer-related behaviors in Maryland was qualitatively similar or higher than that of the United States in 2015, Maryland's 5-year (2011-2015) cancer incidence rate was significantly greater than that of the United States.

CONCLUSIONS

Maryland's 30-year cancer mortality declines have outpaced other states. However, a reduction in mortality while incidence rates remain high indicates a need for enhanced focus on primary prevention.

Prevalence and correlates of job and insurance problems among young breast cancer survivors within 18 months of diagnosis

Background

The prevalence and correlates of job and insurance problems were examined among a cohort of young U.S. breast cancer survivors during the first 18-months following diagnosis.

Methods

Participants were 708 women diagnosed at ≤45 years with stage I-III breast cancer. 90% were non-Hispanic white, 76% were married/partnered and 67% had ≥4-year college degree. Univariable and multivariable logistic regression examined the associations between demographic, lifestyle and clinical factors with job and insurance problems.

Results

18-months after diagnosis, 56% of participants worked full-time, 16% part-time, 18% were homemakers and/or students, 4.5% were unemployed, and 2.4% were disabled. The majority (86%) had private insurance. Job-related problems were reported by 40% of women, and included believing they could not change jobs for fear of losing health insurance (35.0%), being fired (2.3%), and being demoted, denied promotion or denied wage increases (7.8%). Greater job-related problems were associated with being overweight vs. under/normal weight (p = 0.006), income <$50,000/per year (p = 0.01), and working full-time vs. part-time (p = 0.003). Insurance problems were reported by 27% of women, and included being denied health insurance (2.6%), health insurance increases (4.3%), being denied health benefit payments (14.8%) or denied life insurance (11.4%). Insurance problems were associated with being under/normal weight vs. obese (p = 0.01), not being on hormone therapy (p < 0.001), and a tumor size > 5 cm vs. < 2 cm (p = 0.01).

Conclusions

Young survivors experienced significant job- and insurance-related issues following diagnosis. To the extent possible, work and insurance concerns should be addressed prior to treatment to inform work expectations and avoid unnecessary insurance difficulties.

The Affordable Care Act and access to care across the cancer control continuum: A review at 10 years

Lack of health insurance coverage is strongly associated with poor cancer outcomes in the United States. The uninsured are less likely to have access to timely and effective cancer prevention, screening, diagnosis, treatment, survivorship, and end-of-life care than their counterparts with health insurance coverage. On March 23, 2010, the Patient Protection and Affordable Care Act (ACA) was signed into law, representing the largest change to health care delivery in the United States since the introduction of the Medicare and Medicaid programs in 1965. The primary goals of the ACA are to improve health insurance coverage, the quality of care, and patient outcomes, and to maintain or lower costs by catalyzing changes in the health care delivery system. In this review, we describe the main components of the ACA, including health insurance expansions, coverage reforms, and delivery system reforms, provisions within these components, and their relevance to cancer screening and early detection, care, and outcomes. We then highlight selected, well-designed studies examining the effects of the ACA provisions on coverage, access to cancer care, and disparities throughout the cancer control continuum. Finally, we identify research gaps to inform evaluation of current and emerging health policies related to cancer outcomes.

The effect of cancer on the labor supply of employed men over the age of 65

This paper investigates the relationship between cancer diagnosis and the labor supply of employed men over the age of 65. While almost 60% of male cancers are diagnosed in men over the age of 65, no previous research has examined the effect that cancer has on this age group, which is surprising given the relevance of this group to public policy. With data from the Health and Retirement Study, I show that cancer has a significant negative effect on the labor supply of these workers. Using a combination of linear regression models and propensity score matching, I find that respondents who are diagnosed with cancer work 3 fewer hours per week than their non-cancer counterparts. They are also 10 percentage points more likely to stop working. This reduction seems to be driven by a deterioration in physical and mental health.

Impact of sociodemographic characteristics on underemployment in a longitudinal, nationally representative study of cancer survivors: Evidence for the importance of gender and marital status

BACKGROUND

We examined the longitudinal association between sociodemographic factors and an expanded definition of underemployment among those with and without cancer history in the United States.

METHODS

Medical Expenditure Panel Survey data (2007-2013) were used in multivariable regression analyses to compare employment status between baseline and two-year follow-up among adults aged 25-62 years at baseline (n = 1,614 with and n = 39,324 without cancer). Underemployment was defined as becoming/staying unemployed, changing from full to part-time, or reducing part-time work significantly. Interaction effects between cancer history/time since diagnosis and predictors known to be associated with employment patterns, including age, gender/marital status, education, and health insurance status at baseline were modeled.

RESULTS

Approximately 25% of cancer survivors and 21% of individuals without cancer reported underemployment at follow-up (p = 0.002). Multivariable analyses indicated that those with a cancer history report underemployment more frequently (24.7%) than those without cancer (21.4%, p = 0.002) with underemployment rates increasing with time since cancer diagnosis. A significant interaction between gender/marital status and cancer history and underemployment was found (p = 0.0004). There were no other significant interactions. Married female survivors diagnosed >10 years ago reported underemployment most commonly (38.7%), and married men without cancer reported underemployment most infrequently (14.0%). A wider absolute difference in underemployment reports for married versus unmarried women as compared to married versus unmarried men was evident, with the widest difference apparent for unmarried versus married women diagnosed >10 years ago (18.1% vs. 38.7%).

CONCLUSION

Cancer survivors are more likely to experience underemployment than those without cancer. Longer time since cancer diagnosis and gender/marital status are critical factors in predicting those at greatest risk of underemployment. The impact of cancer on work should be systematically studied across sociodemographic groups and recognized as a component of comprehensive survivorship care.

Effects of Affordable Care Act Marketplaces and Medicaid Eligibility Expansion on Access to Cancer Care

PURPOSE

The aim of this study was to inform oncologists about how repealing the Affordable Care Act (ACA) may affect their ability to provide cancer therapies for people with cancer enrolled in ACA health plans and why proposals to change Medicaid funding may make it even more difficult for Medicaid beneficiaries to access cancer treatments.

METHODS

We examined the regulations and provisions of the ACA related to how health insurance impacts access to diagnostic testing and treatments for people with cancer, including access to clinical trials. Similarly, we examined federal and state rules affecting Medicaid beneficiaries' access to cancer treatments.

RESULTS

Repealing various provisions of the ACA will restrict who has access to both current and new cancer treatments. Such changes also will impact oncology research that depends on having heterogeneous people in clinical trials.

CONCLUSIONS

Significant changes to the ACA will affect oncology treatment choices of everyone with health insurance-not only the 10 million people newly covered by ACA health plans and the 70 million people with Medicaid coverage.

Development of Conceptual Framework to Understand Factors Associated with Return to Work among Cancer Survivors: A Systematic Review

This systematic review was conducted to develop a conceptual framework that addresses various factors associated with return to work among cancer survivors. Databases Medline, EMBASE, ProQuest, PubMed and ScienceDirect were systematically searched using medical subject headings [MeSH] for studies published in English from 1990 to 2013. Studies that described adult cancer patients' self-reported data or patients' point of view on factors associated with return to work or employment status following cancer diagnosis were included. Articles selection was conducted in three steps: selection based on title and abstract, retrieval of full text and additions of articles from reference lists and recommendations from experts. Disagreement in data extraction was solved by consultation of third reviewer. Out of twenty seven articles, breast cancer was the most studied type of cancer (30%) while colorectal cancer was studied independently in two articles (7.4%). Conceptual framework on return to work identifies factors under environmental, personal, work demand, work ability, health status and financial factors. Extensive search of scientific databases over last 24 years and the development of the conceptual frame-work are the strength of this review. Conceptual framework reveals the various factors including non-medical factors associated with return to work upon cancer diagnosis. It serves as a reminder to the policy makers to focus on modifiable factors as potential areas for intervention to assist cancer survivors return to work, especially those with little financial assistance and health insurance.

Does cancer reduce labor market entry? Evidence for prime-age females

Existing studies of the labor market status of cancer survivors have focused on the extent to which cancer disrupts the employment of individuals who were working when diagnosed with cancer. We examine how surviving cancer affects labor market entry and usual hours of work among females aged 28 to 54 years who were not working when first diagnosed. We find that prime-age females have employment rates 2 to 6 years after diagnosis that are 12 percentage points lower than otherwise similar women who were initially out of the labor force, full-time employment rates that are 10 percentage points lower, and usual hours of work that are 5 hours per week lower. These estimates are somewhat larger than estimates for prime-age women employed at the time of diagnosis and highlight the importance of considering nonworking females when assessing the economic and psychosocial burden of cancer.

Does employer-provided health insurance constrain labor supply adjustments to health shocks? New evidence on women diagnosed with breast cancer

Employment-contingent health insurance may create incentives for ill workers to remain employed at a sufficient level (usually full-time) to maintain access to health insurance coverage. We study employed married women, comparing the labor supply responses to new breast cancer diagnoses of women dependent on their own employment for health insurance with the responses of women who are less dependent on their own employment for health insurance, because of actual or potential access to health insurance through their spouse's employer. We find evidence that women who depend on their own job for health insurance reduce their labor supply by less after a diagnosis of breast cancer. In the estimates that best control for unobservables associated with health insurance status, the hours reduction for women who continue to work is 8 to 11% smaller. Women's subjective responses to questions about working more to maintain health insurance are consistent with the conclusions from observed behavior.

Employer-sponsored health insurance coverage limitations: results from the Childhood Cancer Survivor Study

PURPOSE

The Affordable Care Act (ACA) will expand health insurance options for cancer survivors in the USA. It is unclear how this legislation will affect their access to employer-sponsored health insurance (ESI). We describe the health insurance experiences for survivors of childhood cancer with and without ESI.

METHODS

We conducted a series of qualitative interviews with 32 adult survivors from the Childhood Cancer Survivor Study to assess their employment-related concerns and decisions regarding health insurance coverage. Interviews were performed from August to December 2009 and were recorded, transcribed, and content analyzed using NVivo 8.

RESULTS

Uninsured survivors described ongoing employment limitations, such as being employed at part-time capacity, which affected their access to ESI coverage. These survivors acknowledged they could not afford insurance without employer support. Survivors on ESI had previously been denied health insurance due to their preexisting health conditions until they obtained coverage through an employer. Survivors feared losing their ESI coverage, which created a disincentive to making career transitions. Others reported worries about insurance rescission if their cancer history was discovered. Survivors on ESI reported financial barriers in their ability to pay for health care.

CONCLUSIONS

Childhood cancer survivors face barriers to obtaining ESI. While ACA provisions may mitigate insurance barriers for cancer survivors, many will still face cost barriers to affording health care without employer support.

The effects of health shocks on employment and health insurance: the role of employer-provided health insurance

Employment-contingent health insurance (ECHI) has been criticized for tying insurance to continued employment. Our research sheds light on two central issues regarding employment-contingent health insurance: whether such insurance "locks" people who experience a health shock into remaining at work; and whether it puts people at risk for insurance loss upon the onset of illness, because health shocks pose challenges to continued employment. We study how men's dependence on their own employer for health insurance affects labor supply responses and health insurance coverage following a health shock. We use the Health and Retirement Study (HRS) surveys from 1996 through 2008 to observe employment and health insurance status at interviews 2 years apart, and whether a health shock occurred in the intervening period between the interviews. All employed married men with health insurance either through their own employer or their spouse's employer, interviewed in at least two consecutive HRS waves with non-missing data on employment, insurance, health, demographic, and other variables, and under age 64 at the second interview are included in the study sample. We then limited the sample to men who were initially healthy. Our analytical sample consisted of 1,582 men of whom 1,379 had ECHI at the first interview, while 203 were covered by their spouse's employer. Hospitalization affected 209 men with ECHI and 36 men with spouse insurance. A new disease diagnosis was reported by 103 men with ECHI and 22 men with other insurance. There were 171 men with ECHI and 25 men with spouse employer insurance who had a self-reported health decline. Labor supply response differences associated with ECHI-with men with health shocks and ECHI more likely to continue working-appear to be driven by specific types of health shocks associated with future higher health care costs but not with immediate increases in morbidity that limit continued employment. Men with ECHI who have a self-reported health decline are significantly more likely to lose health insurance than men with insurance through a spouse. With the passage of health care reform, the tendency of men with ECHI as opposed to other sources of insurance to remain employed following a health shock may be diminished, along with the likelihood of losing health insurance.

Case management needs of older and elderly cancer survivors

PURPOSE/OBJECTIVES

The purpose of this study was to examine the case management needs of older and elderly adults. The specific aim was to describe the results of a survey distributed to cancer survivors, asking them to respond to questions about their specific needs. The survey targeted the physical, psychosocial, social, and spiritual needs.

PRIMARY PRACTICE SETTING

Outpatient setting, outreach program.

FINDINGS/CONCLUSIONS

Fatigue, fear of reoccurrence, and sleep disturbances were of the greatest concern to the older and elderly cancer survivor.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

Case managers dealing with elderly cancer survivors can target these needs in terms of transitions from inpatient to outpatient care and beyond into the survivorship period.

A cohort study of permanently reduced work ability in breast cancer patients

PURPOSE

The aims of this cohort study were to explore various longitudinal aspects of employment and disability pension due to permanently reduced work ability among women with breast cancer and to investigate the impact of breast cancer on income.

PATIENTS AND METHODS

In a national register-based controlled cohort study from Norway, 1,548 women diagnosed with breast cancer (all stages) between 1992 and 1996 at the age 45-54 years and 1,548 cancer-free women matched for age, municipality and civil status were followed for up to 14 years. Medical data from the Cancer Registry of Norway were linked with longitudinal data on employment, social security benefits and socio-demography collected from other national official registries.

RESULTS

Compared to cancer-free controls, breast cancer patients were significantly more likely to receive disability pension (hazard ratio (HR) 2.7, 95% CI 2.3-3.2) after adjustment for unmatched socio-demographic variables (education, income and children <18 years in the household). Adjusted HR in breast cancer stage I patients was 1.8 (95% CI 1.5-2.3) and 3.0 (95% CI 2.4-3.8) in stage II/III patients compared to controls. The risk increased with mastectomy compared to breast-conserving surgery (HR 1.5, 95% CI 1.2-1.9). At the end of the observation period, employment rates were higher in non-disabled patients than in non-disabled controls (82% vs. 77%, p = 0.008). Working breast cancer patients experienced a temporary negative effect on employment income.

CONCLUSION

A considerable proportion of women with breast cancer will over time experience permanently reduced work ability and become disability pension holders. In case of reduced work ability in breast cancer survivors, medical personel caring for them should consider and discuss with them rehabilitation and workplace adjustment in order to prevent early disability pension.

The implications of cancer survivorship for spousal employment

BACKGROUND

The purpose of this research was to estimate employment effects for spouses of cancer survivors who were working at the time of the cancer diagnosis.

METHODS

Spouses of cancer survivors were drawn from the Penn State Cancer Survivor Survey. Comparable spouses of individuals without cancer were drawn from the Panel Survey of Income Dynamics. The final sample included 827 spouses of cancer survivors (542 husbands, 285 wives) and 2,766 spouses of individuals without cancer (1,459 husbands, 1,307 wives). Three employment outcomes were studied 2-6 years after diagnosis: whether working, whether working full time (35+ hours per week), and usual hours per week. We used propensity scores to match cases to controls 3:1.

RESULTS

Wives of cancer survivors had a lower probability (-7.5 percentage points) of being employed 2-6 years after diagnosis (p  =  0.036). They were slightly more likely to be working full time, while averaging 1.1 fewer hours per week overall, but these effects were not statistically significant. Cancer's effect on husbands was not significant for any of the employment outcomes. However, if survivor wives and husbands were working at follow-up, they had more than twice the odds of working full-time (wives OR = 2.18, p  =  0.0004; husbands OR = 2.65, p  =  0.012) and worked more hours per week than other spouses (wives 1.9, p  =  0.041; husbands 1.5, p  =  0.04).

CONCLUSIONS

The implications to cancer survivors and their spouses of these results is that the employment of survivor spouses, especially of wives, is somewhat reshaped by cancer in the medium to long run. However, there is little or no effect on aggregate hours worked by spouses who were employed at diagnosis.

Employment among survivors of lung cancer and colorectal cancer

PURPOSE

To identify the frequency of and factors associated with changes in employment among cancer survivors.

METHODS

This prospective cohort study took place in the context of the population-based Cancer Care Outcomes Research and Surveillance Consortium. Patients with nonmetastatic lung or colorectal cancer who survived approximately 15 months after diagnosis without cancer recurrence provided their self-reported employment status, employment experiences, and changes in insurance coverage at 4 and 15 months after diagnosis. Multiple logistic regression was used to relate sociodemographic and disease factors to the probability of labor force departure.

RESULTS

Among 2,422 eligible patients, employment declined from 3% to 31% over the 15 months after cancer was diagnosed. Labor force departures attributable to cancer occurred in 17% of those employed at baseline. Factors associated with significantly higher rates of labor force departure were lung versus colon cancer, stage III versus I or II disease, lower educational and income levels, and, among colorectal patients, older age. Married women were significantly more likely than unmarried women to leave the workforce. Only 2% of patients lacked health insurance during the study period.

CONCLUSION

Most employed patients with nonmetastatic lung or colorectal cancer return to work, but approximately one sixth of patients leave the workforce, particularly those with worse prognoses or lower socioeconomic status. Potential economic effects must be considered in management decisions about cancer.