Abstract C20: Financial strain in people struggling with health care costs
Authors: Humble Sarah , McQueen Amy , Lewis Marquita , Hunleth Jean , McCray Natasan , Lee Amanda , Ibrao Miquela , James Aimee 
Published: February 2019

Abstract
Background: Financial distress and financial strain have received increasing attention in the health disparities literature. This is partly because the costs of some illnesses, such as cancer, can lead to “financial toxicity.” It is also because some health care costs, from screening/diagnosis to treatment, are unaffordable to many patients. Cost concerns are a commonly mentioned barrier to adherence, but affordability and financial strain have remained underexamined in the public health and medical literatures. As a result, there are no standard measurement strategies. In an ongoing study, we aim to disentangle elements of financial strain, develop a comprehensive assessment of strain, and then examine how strain affects health care choices including adherence to medical recommendations.
Methods: We reviewed the literature to compile measures of financial strain and financial distress. We then conducted 26 cognitive interviews to pretest the questions with community members. We sought to develop a set of items that were sensitive to respondents' life contexts (e.g., avoid questions about vacations). Survey questions were iteratively deleted and revised based on participant feedback. Participants' responses indicated that some financial experiences were not captured, so we added questions to address the omissions. Then, we recruited participants through newspaper ads and a Federally Qualified Health Center for the final interviewer-administered questionnaire. Data were collected on tablets for direct input into REDCap. To describe financial strain, we conducted descriptive analyses.
Results: Our analysis is based on the first 169 survey participants (51% female; 82% African American; mean age = 56) in our ongoing study. Few (9%) had private insurance, 15% had no insurance, and 22% were uninsured but enrolled in a local health care coverage program. We asked about a range of financial strains. Many participants (63%) had outstanding medical bills (34% of whom owed &gt; $5000). In the past year, many (&gt;50%) had a bill that was past due, had paid the minimum on a utility bill, or paid a utility bill late in the last year; fewer had their utilities (20%) or phone (40%) cut off. Participants commonly reported that in the last year, they very often (31%) or fairly often (33%) did not have enough money for the things they needed. In particular, 30% said they could not currently afford a suitable place to stay, 64% could not afford suitable clothing, and 76% could not afford an adequate car or other form of transportation. About half of respondents said they sometimes, most of the time, or always ran out of food by the end of the month. Unexpected expenses were a concern for participants: nearly half said they did not have enough money to pay for a minor emergency, and 40% had “no confidence” that they could pay for an emergency of $300. Some had people they could go to if they were “short on funds,” but just as many said others asked them for money. Financial strain affected physical health, social relationships, and what people could buy for people and children in their lives.
Discussion: Many low-income people struggle with multiple and inter-related aspects of financial strain. They engage in cost-coping strategies and make choices about how to prioritize expenses, needs, and health care with limited and often insufficient funds. Unexpected expenses or loss of income can have a significant impact. Financial strain is multifaceted, and developing valid measures that are sensitive and contextually relevant is important. Standard measures will allow us to better examine the effects of financial strain on health behaviors and outcomes. In our program of research, we will continue to collect data so that we can identify the best financial strain items through tests of content, construct, and predictive validity, and then assess the role of financial strain in health care choices.
Citation Format: Sarah Humble, Amy McQueen, Marquita Lewis, Jean Hunleth, Natasan McCray, Amanda Lee, Miquela Ibrao, Aimee James. Financial strain in people struggling with health care costs [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr C20.