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. 2022 Aug 5;17(8):e0272740. doi: 10.1371/journal.pone.0272740

Health insurance and financial hardship in cancer survivors during the COVID-19 pandemic

Courtney P Williams 1,*, Gabrielle B Rocque 1, Nicole E Caston 1, Kathleen D Gallagher 2, Rebekah S M Angove 2, Eric Anderson 2, Janet S de Moor 3, Michael T Halpern 3, Anaeze C Offodile II 4, Risha Gidwani 5
Editor: Raymond Nienchen Kuo6
PMCID: PMC9355233  PMID: 35930603

Abstract

Uninsured or underinsured individuals with cancer are likely to experience financial hardship, including forgoing healthcare or non-healthcare needs such as food, housing, or utilities. This study evaluates the association between health insurance coverage and financial hardship among cancer survivors during the COVID-19 pandemic. This cross-sectional analysis used Patient Advocate Foundation (PAF) survey data from May to July 2020. Cancer survivors who previously received case management or financial aid from PAF self-reported challenges paying for healthcare and non-healthcare needs during the COVID-19 pandemic. Associations between insurance coverage and payment challenges were estimated using Poisson regression with robust standard errors, which allowed for estimation of adjusted relative risks (aRR). Of 1,437 respondents, 74% had annual household incomes <$48,000. Most respondents were enrolled in Medicare (48%), 22% in employer-sponsored insurance, 13% in Medicaid, 6% in an Affordable Care Act (ACA) plan, and 3% were uninsured. Approximately 31% of respondents reported trouble paying for healthcare during the COVID-19 pandemic. Respondents who were uninsured (aRR 2.58, 95% confidence interval [CI] 1.83–3.64), enrolled in an ACA plan (aRR 1.86, 95% CI 1.28–2.72), employer-sponsored insurance (aRR 1.70, 95% CI 1.23–2.34), or Medicare (aRR 1.49, 95% CI 1.09–2.03) had higher risk of trouble paying for healthcare compared to Medicaid enrollees. Challenges paying for non-healthcare needs were reported by 57% of respondents, with 40% reporting trouble paying for food, 31% housing, 28% transportation, and 20% internet. In adjusted models, Medicare and employer-sponsored insurance enrollees were less likely to have difficulties paying for non-healthcare needs compared to Medicaid beneficiaries. Despite 97% of our cancer survivor sample being insured, 31% and 57% reported trouble paying for healthcare and non-healthcare needs during the COVID-19 pandemic, respectively. Greater attention to both medical and non-medical financial burden is needed given the economic pressures of the COVID-19 pandemic.

Introduction

Despite an increase in insurance coverage rates due to the passage of the Patient Protection and Affordable Care Act (ACA) [1], rates of underinsurance remain high among Americans with cancer [2]. Underinsurance, often characterized by spending >10% of household income on healthcare, is associated with cancer treatment delays and financial distress [3, 4]. Job layoffs and economic insecurity stemming from the COVID-19 pandemic are likely to increase rates of uninsurance and underinsurance [5]. For cancer survivors, these increases may be associated with financial hardship and result in forgone healthcare or non-healthcare purchases, such as food, housing, or utilities. This study examines the relationship between health insurance coverage and challenges paying for healthcare and non-healthcare needs during the COVID-19 pandemic in adults with cancer.

Materials and methods

This analysis used secondary, cross-sectional survey data from individuals who had previously received case management or financial aid from Patient Advocate Foundation (PAF), a non-profit organization that helps individuals with chronic illnesses access recommended care. Internet surveys were fielded from May 20 to July 12, 2020. Survey participation was incentivized via drawings for six individual $25 gift cards. Respondents provided written informed consent for all PAF survey communications. The University of Alabama at Birmingham Institutional Review Board approved this secondary analysis of the PAF survey data. Respondents reported challenges paying for healthcare and non-healthcare needs using the single-item survey question, “Have you had trouble paying for any of the following since the beginning of the COVID-19 pandemic?” Respondents were then asked to select all that applied, which included food, household supplies, housing (rent or mortgage), utilities, phone, internet/data, car/gas/transportation, childcare/eldercare/home health services, and healthcare/medical costs (e.g., prescription medications, doctor’s visits, clinical/hospital services, medical supplies).

Associations between insurance coverage and challenges affording healthcare or non-healthcare needs during the COVID-19 pandemic were estimated using adjusted relative risks (aRR) and 95% confidence intervals (CI) from modified Poisson models with robust standard errors [6]. Use of modified Poisson regression with sandwich errors for analysis of binary outcomes produces reliable estimates of relative risk, which is more easily interpretable than odds ratios produced by logistic regression [6]. Models were adjusted for age, sex, race and ethnicity, household income, education, employment, rurality, cancer type, and comorbidity count.

Results

Surveys were e-mailed to 15,857 PAF clients and completed by 4,108 (26% response rate; S1 Table). Of 1,437 respondents reporting a previous cancer diagnosis, 38% were aged <55 years, 23% were Black or African American, 74% had annual household incomes <$48,000, and 40% had a bachelor’s degree or higher (Table 1). Breast cancer was most common among respondents (35%), and 41% reported ≥3 additional comorbidities. Most respondents were enrolled in Medicare (48%), 22% in employer-sponsored insurance, 13% in Medicaid, 6% in an ACA plan, and 3% were uninsured.

Table 1. Respondent sociodemographic and clinical characteristics (N = 1437).

Total N = 1437
Age
    19–35 60 (4.2)
    36–55 490 (34.1)
    56–75 790 (55.0)
    ≥ 76 97 (6.8)
Sex
    Male 404 (28.1)
    Female 1033 (71.9)
Race and ethnicity
    White 851 (59.2)
    Black/African American 336 (23.4)
    Hispanic/Latino 120 (8.4)
    Other 76 (5.3)
    Unknown 54 (3.8)
Education
    Less than high school 41 (2.9)
    High school degree 321 (22.3)
    Some college 501 (34.9)
    ≥ Bachelor’s degree 569 (39.6)
    Unknown 5 (0.4)
Employment status
    Employed 307 (21.4)
    Retired 397 (27.6)
    Disabled 535 (37.3)
    Unemployed/other 198 (13.8)
Household income
    ≤$47,999 1061 (73.8)
    >$47,999 359 (25.0)
    Unknown 17 (1.2)
Rural-Urban Commuting Area
    Urban 1083 (75.4)
    Rural 137 (9.5)
    Unknown 217 (15.1)
Cancer type
    Breast 497 (34.6)
    Genitourinary 83 (5.8)
    Gynecological 38 (2.6)
    Gastrointestinal 75 (5.2)
    Hematologic 429 (29.9)
    Other 315 (21.9)
Comorbidity count*
    0 583 (40.6)
    1–2 482 (33.5)
    ≥3 372 (25.9)
Health insurance status
    Employer-sponsored 322 (22.4)
    ACA 90 (6.3)
    Medicare 694 (48.3)
    Medicaid 185 (12.9)
    Uninsured 49 (3.4)
    Other / unknown 97 (6.8)
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*Count of comorbidities other than cancer

ACA = Affordable Care Act

Overall, 31% of respondents reported challenges paying for healthcare during the COVID-19 pandemic (Fig 1). In adjusted models, respondents who were uninsured (aRR 2.58, 95% CI 1.83–3.64), enrolled in an ACA plan (aRR 1.86, 95% CI 1.28–2.72), employer-sponsored insurance (aRR 1.70, 95% CI 1.23–2.34), or Medicare (aRR 1.49, 95% CI 1.09–2.03) were more likely to report trouble paying for healthcare compared to Medicaid enrollees (Table 2).

Fig 1. Proportion of respondents reporting trouble paying for healthcare and non-healthcare needs during the COVID-19 pandemic by health insurance status (N = 1437).

Fig 1

Open in a new tab

Table 2. Adjusted model results estimating relative risk of trouble paying for healthcare or any non-healthcare need in cancer survivors (N = 1437).

Trouble paying for healthcare Trouble paying for any non-healthcare need
Relative Risk Relative Risk
(95% Confidence Interval) (95% Confidence Interval)
Health insurance status
    Medicaid Ref. Ref.
    Affordable Care Act 1.86 (1.28–2.72) 0.88 (0.75–1.03)
    Employer-sponsored 1.70 (1.23–2.34) 0.78 (0.69–0.87)
    Medicare 1.49 (1.09–2.03) 0.76 (0.68–0.84)
    Uninsured 2.58 (1.83–3.64) 0.91 (0.77–1.07)
    Other / unknown 1.44 (0.96–2.18) 0.83 (0.71–0.98)
Age
    19–35 Ref. Ref.
    36–55 1.23 (0.82–1.85) 0.98 (0.83–1.16)
    56–75 1.14 (0.75–1.73) 0.83 (0.70–0.99)
    ≥ 76 1.02 (0.57–1.82) 0.61 (0.42–0.89)
Sex
    Male Ref. Ref.
    Female 0.96 (0.78–1.19) 1.04 (0.92–1.17)
Race and ethnicity
    White Ref. Ref.
    Black/African American 0.99 (0.82–1.19) 1.31 (1.20–1.43)
    Hispanic/Latino 1.19 (0.91–1.56) 1.16 (1.02–1.32)
    Other 1.14 (0.83–1.57) 1.00 (0.82–1.22)
Education
    Less than high school Ref. Ref.
    High school degree 1.28 (0.71–2.30) 0.91 (0.74–1.11)
    Some college 1.44 (0.81–2.55) 0.93 (0.76–1.14)
    ≥ Bachelor’s degree 1.37 (0.77–2.45) 0.86 (0.70–1.06)
Employment status
    Employed Ref. Ref.
    Retired 0.81 (0.61–1.09) 0.58 (0.47–0.70)
    Disabled 1.13 (0.90–1.41) 1.13 (1.00–1.27)
    Unemployed/other 1.21 (0.94–1.56) 1.08 (0.95–1.23)
Household income
    ≤ $47,999 Ref. Ref.
    > $47,999 1.00 (0.83–1.21) 0.89 (0.80–1.00)
Rural-Urban Commuting Area
    Urban Ref. Ref.
    Rural 1.25 (0.99–1.58) 0.93 (0.80–1.07)
Cancer type
    Breast Ref. Ref.
    Genitourinary 0.71 (0.43–1.16) 0.84 (0.63–1.11)
    Gynecological 1.10 (0.74–1.66) 0.89 (0.67–1.17)
    Gastrointestinal 0.87 (0.59–1.29) 1.00 (0.84–1.18)
    Hematologic 0.78 (0.63–0.98) 1.02 (0.91–1.14)
    Other 1.06 (0.86–1.30) 0.99 (0.89–1.11)
Comorbidity count*
    0 Ref. Ref.
    1–2 1.10 (0.90–1.33) 1.05 (0.94–1.16)
    ≥ 3 1.50 (1.24–1.82) 1.30 (1.18–1.44)
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*Count of comorbidities other than cancer

Challenges paying for non-healthcare needs during the COVID-19 pandemic were reported by 57% of respondents, with 40% reporting trouble paying for food, 32% for housing, 28% for transportation, and 20% for internet (Fig 1). In adjusted models, respondents enrolled in Medicare (aRR 0.76, 95% CI 0.68–0.84) or employer-sponsored insurance (aRR 0.78, 95% CI 0.69–0.87) were less likely to report challenges paying for non-healthcare needs compared to Medicaid enrollees (Table 2). In adjusted models of specific non-healthcare needs, Medicare beneficiaries and respondents enrolled in employer-sponsored plans were less likely to report trouble paying for food, household supplies, housing, utilities, a phone, internet or data, and transportation compared to Medicaid beneficiaries (S2 Table).

Discussion

Individuals with cancer are dealing with many financial challenges potentially associated with the COVID-19 pandemic, with 57% of our sample reporting trouble paying for non-healthcare needs and 31% reporting trouble paying for healthcare. Our results suggest the financial hardship experienced by cancer survivors may have been exacerbated during the COVID-19 pandemic when compared to pre-pandemic estimates, such as those in a recent study by Han and colleagues. Using the 2016 Medical Expenditures Panel Survey data, Han estimated 16% of cancer survivors experienced material financial hardship, which includes reduced spending on non-healthcare needs, and 27% experienced delayed or forgone health care due to cost [7]. Our study also showed risk of payment challenges differed by insurance coverage status. Medicaid beneficiaries were at lowest risk of challenges paying for healthcare, but highest risk of trouble affording non-healthcare needs. Conversely, respondents enrolled in an ACA plan, employer-sponsored insurance, or Medicare were more likely to report difficulties in paying for healthcare compared to Medicaid enrollees.

Our results suggest private insurance and Medicare coverage may not sufficiently protect against out-of-pocket medical costs in individuals with cancer. In our study, individuals with ACA, employer-sponsored, or Medicare insurance were at higher risk of trouble paying for healthcare during the COVID-19 pandemic compared to Medicaid enrollees. This is likely due to substantial cost sharing requirements posed by these insurance mechanisms. An estimated 47% of privately-insured patients are enrolled in high-deductible health plans [8]. In 2020, individual silver plan ACA deductibles averaged $4,450 and 26% of individuals with employer-sponsored insurance had annual deductibles of at least $2,000 [9, 10]. After deductibles are met, normal patient cost-sharing provisions such as copayments or coinsurance apply. Though the majority of Medicare beneficiaries are enrolled in supplemental coverage which offsets beneficiary Medicare Parts A and B cost sharing, Medicare Part D, which covers many oral anticancer medications, has no cap on patient out-of-pocket costs and imposes 25% co-insurance during the initial coverage period and in the coverage gap. Because the mean anticancer medication price was almost $14,000 in 2018, this benefit design commonly results in high out-of-pocket spending for enrollees with a cancer diagnosis [11]. Conversely, out-of-pocket costs for premium and cost sharing are capped at 5% of household income for all Medicaid enrollees [12]. Efforts towards increasing provider awareness of potential financial hardship in insured patients is needed during treatment and survivorship care planning.

On the other hand, over half of our study respondents reported trouble paying for non-healthcare needs during the COVID-19 pandemic, with similar risks of trouble found in respondents who were uninsured, ACA-insured, and enrolled in Medicaid. Difficulties in paying for non-medical necessities can affect cancer outcomes. Food-insecure cancer survivors have higher odds of forgone, delayed, or altered cancer treatment than those who are food secure [13]. Challenges paying for transportation, cited by almost one-third of our study respondents and half of Medicaid enrollees, can compound quickly and negatively impact receipt of care [14]. The pandemic-induced shifts to telehealth may not sufficiently offset access challenges stemming from transportation, as 53% of respondents in our study reporting transportation cost challenges also reported trouble affording internet [15]. While addressing food or housing insecurity may extend beyond the immediate scope of clinical practice, provider inquiry and accommodation of patient transportation and internet challenges, such as scheduling same-day appointments with cancer care team members, could reduce financial burden and improve receipt of recommended care. Of note, ACA-insured and Medicaid patients reported similar levels of difficulty in paying for non-healthcare necessities. However, there is no differentiation between ACA or employer-sponsored insurance in the electronic medical record. Patients with either type of coverage will appear as privately insured. Thus, providers should be aware that many of their privately insured patients face the same financial challenges as their Medicaid patients, and may wish to extend any discussions of financial burden or assistance to their privately insured patients as well.

The results of our study should be considered within limitations. The survey captures data from cancer survivors who previously received help accessing or paying for care from PAF and may not be representative of the larger cancer patient population. Information potentially associated with health insurance coverage and challenges paying for healthcare and non-healthcare needs, such as time since cancer diagnosis, current health care use or needs, and more detailed demographic information, was limited by use of secondary data. The results of our study could have been impacted by pandemic-related employment changes. However, this was uncommon in our study with only 2% of respondents reporting employment loss due to the COVID-19 pandemic. We had a low survey response rate, potentially due to the COVID-19 pandemic, which may result in selection bias. Our sample may also be biased towards individuals able to navigate services from a non-profit organization or access web-based surveys.

Conclusions

In this sample of cancer survivors, 31% and 57% reported trouble paying for healthcare and non-healthcare needs during the COVID-19 pandemic, respectfully. Those with private insurance or Medicare were more likely to report trouble paying for healthcare, while those enrolled in Medicaid most often reported trouble paying for non-healthcare needs. System-level efforts towards ensuring insurance coverage adequately addresses healthcare needs and provider-level efforts to incorporate financial information in clinical decision-making could aid in reducing patient-level financial hardship associated with the COVID-19 pandemic.

Supporting information

S1 Table. Non-respondent sociodemographic characteristics (N = 11,749).

(DOCX)

Click here for additional data file. (14.5KB, docx)
S2 Table. Adjusted model results estimating relative risk of trouble paying for non-healthcare necessities in under-resourced cancer survivors (N = 1,437).

(DOCX)

Click here for additional data file. (27.9KB, docx)

Acknowledgments

Previous presentations: This work was presented as a poster presentation at the virtual 2021 Academy Health Annual Research Meeting, June 14–17, 2021.

Data Availability

Data that support the findings of this study was collected for organizational and programmatic purposes by Patient Advocate Foundation and may be available upon request. Participants of this study did not agree for their data to be shared publicly. Use of data from Patient Advocate Foundation for analytic purposes requires a data use agreement that is reviewed by the external compliance officer prior to signature by both parties. Please contact PAF Compliance Officer Stephanie Trunk (Stephanie.trunk@patientadvocate.org) with inquiries.

Funding Statement

The author(s) received no specific funding for this work.

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Decision Letter 0

Raymond Nienchen Kuo

25 Jan 2022

PONE-D-21-32975Health insurance and financial hardship in cancer survivors during the COVID-19 pandemicPLOS ONE

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Reviewer #1: This is a well written and important topic on financial burden for cancer patients in the United States during the pandemic. Overall this is a well thought out paper, but I do have a few significant suggestions, and one minor comment.

Significant

1. The authors have made no attempt to identify how the financial impact to patients has changed since the pandemic. I am not suggesting additional analysis, but rather an examination of data pre-pandemic to see if the impact is different (or the same) as it was pre-pandemic in the discussion or limitations.

2. The authors have not addressed the overall impact on employment during the pandemic. Although some federal funding was provided in many cases this would have been a decrease over their regular income stream. Again I am not suggesting additional analysis but at a minimum this needs to be highlighted in the limitations, or an examination of the literature on this topic should be included in the discussion.

Minor

pg 12 of 21 line 122 "which covers may oral..." should read "which covers many oral..."

Reviewer #2: This is a well-written and concise analysis, and it provides a meaningful addition to the growing (and necessary) body of literature on the impact of COVID-19 on cancer patients and survivors. I particularly appreciate your including cost of internet in your survey, as this is, as you note, a potential barrier to telehealth uptake and may limit survivors' ability to engage with other aspects of the healthcare system as well. My comments are minimal but include the following:

1) Please consider omitting your use of "under-resourced" throughout the manuscript, or at least provide a clear definition to understand the research team's characterization of this term.

2) Did you collect any information on time since treatment or diagnosis, or on the respondents' current healthcare use/needs? If so, please report; if not, please note as a limitation, as these factors, particularly current healthcare needs, may influence one's difficulty paying for healthcare use.

3) Please provide more detail on how your outcomes of interest were measured? Were these yes/no questions, or did you use a scale? If the latter, provide detail on how the scale was dichotomized.

4) Was age collected as a continuous variable, or was it collected in the categories reported in Table 1? If the former, consider revising your categorizations more meaningfully to reflect age 65 as the age of Medicare eligibility and 18-39 as the NCI's definition of young adult. Similarly, how was the income threshold of $48K determined?

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #2: No

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PLoS One. 2022 Aug 5;17(8):e0272740. doi: 10.1371/journal.pone.0272740.r002

Author response to Decision Letter 0

25 Apr 2022

February 21, 2022

Raymond Nienchen Kuo, PhD, Academic Editor

PLOS ONE

Manuscript title: Health insurance and financial hardship in cancer survivors during the COVID-19 pandemic

Dear Dr. Kuo and Reviewers,

We wish to thank the reviewers for their thoughtful comments and for the opportunity to respond. Please see our response below and the updated manuscript for our responses to the reviewer’s suggestions.

Thank you again for your consideration of this manuscript.

Response to journal requirements:

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Response: We have edited our manuscript to meet the PLOS ONE style requirements.

2. Please amend your current ethics statement to address the following concerns:

a) Did participants provide their written or verbal informed consent to participate in this study?

b) If consent was verbal, please explain i) why written consent was not obtained, ii) how you documented participant consent, and iii) whether the ethics committees/IRB approved this consent procedure.

Response: Survey respondents provided electronic, written consent for their participation in this survey. We have clarified this in the methods section.

“Respondents provided written informed consent for all PAF survey communications. The University of Alabama at Birmingham Institutional Review Board approved this secondary analysis of the PAF survey data.”

3. Thank you for stating the following in the Competing Interests section: "I have read the journal's policy and the authors of this manuscript have the following competing interests: Dr. Rocque is supported by an American Cancer Society Mentored Research Scholar Grant (MRSG-17-051-01-PCSM) and has received research funding from Genentech, Pfizer, and Carevive and consulting fees for Genentech and Pfizer." We note that you received funding from a commercial source: Genentech. Please provide an amended Competing Interests Statement that explicitly states this commercial funder, along with any other relevant declarations relating to employment, consultancy, patents, products in development, marketed products, etc. Within this Competing Interests Statement, please confirm that this does not alter your adherence to all PLOS ONE policies on sharing data and materials by including the following statement: "This does not alter our adherence to PLOS ONE policies on sharing data and materials.” (as detailed online in our guide for authors http://journals.plos.org/plosone/s/competing-interests). If there are restrictions on sharing of data and/or materials, please state these. Please note that we cannot proceed with consideration of your article until this information has been declared. Please include your amended Competing Interests Statement within your cover letter. We will change the online submission form on your behalf.

Response: We have edited our Competing Interests Statement to the following: “I have read the journal's policy and the authors of this manuscript have the following competing interests: Dr. Rocque is supported by an American Cancer Society Mentored Research Scholar Grant (MRSG-17-051-01-PCSM) and has received research funding from Genentech, Pfizer, and Carevive and consulting fees for Genentech and Pfizer for work unrelated to the current study. This does not alter our adherence to PLOS ONE policies on sharing data and materials.” We have also included this in our updated cover letter.

We have edited our data availability statement to the following: “Data that support the findings of this study was collected for organizational and programmatic purposes by Patient Advocate Foundation and may be available upon request. Participants of this study did not agree for their data to be shared publicly.”

4. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Response: We have reviewed our reference list and confirm it is complete and correct.

Response to reviewer comments:

Reviewer 1

This is a well written and important topic on financial burden for cancer patients in the United States during the pandemic. Overall this is a well thought out paper, but I do have a few significant suggestions, and one minor comment.

Significant

1. The authors have made no attempt to identify how the financial impact to patients has changed since the pandemic. I am not suggesting additional analysis, but rather an examination of data pre-pandemic to see if the impact is different (or the same) as it was pre-pandemic in the discussion or limitations.

Response: We agree this is an important issue to address and have added to our discussion section using data from Han and colleagues (https://doi.org/10.1158/1055-9965.EPI-19-0460).

“Our results suggest the financial hardship experienced by cancer survivors may have been exacerbated during the COVID-19 pandemic when compared to pre-pandemic estimates, such as those in a recent study by Han and colleagues. Using the 2016 Medical Expenditures Panel Survey data, Han estimated 16% of cancer survivors experienced material financial hardship, which includes reduced spending on non-healthcare needs, and 27% experienced delayed or forgone health care due to cost.”

2. The authors have not addressed the overall impact on employment during the pandemic. Although some federal funding was provided in many cases this would have been a decrease over their regular income stream. Again I am not suggesting additional analysis but at a minimum this needs to be highlighted in the limitations, or an examination of the literature on this topic should be included in the discussion.

Response: We appreciate this very relevant suggestion. COVID-related employment changes were uncommon in our study, with 2% of respondents self-reporting pandemic-related loss of employment. Notably, 65% of our sample reported being retired or disabled at the time the survey data was collected, which suggests most of our sample would not be affected by pandemic-related employment changes. Furthermore, for minimum-wage earners in our sample, receipt of unemployment benefits may have also resulted in income increases rather than decreases. We have added these details to our limitation section.

“The results of our study could have been impacted by pandemic-related employment changes. However, this was uncommon in our study with only 2% of respondents reporting employment loss due to the COVID-19 pandemic.“

Minor

3. pg 12 of 21 line 122 "which covers may oral..." should read "which covers many oral..."

Response: Thank you for the attention to detail. We have edited accordingly.

Reviewer 2

This is a well-written and concise analysis, and it provides a meaningful addition to the growing (and necessary) body of literature on the impact of COVID-19 on cancer patients and survivors. I particularly appreciate your including cost of internet in your survey, as this is, as you note, a potential barrier to telehealth uptake and may limit survivors' ability to engage with other aspects of the healthcare system as well. My comments are minimal but include the following:

1. Please consider omitting your use of "under-resourced" throughout the manuscript, or at least provide a clear definition to understand the research team's characterization of this term.

Response: Thank you for this suggestion. We have deleted the term “under-resourced” from our manuscript. We have also clarified the potential sample bias in our limitations.

“The survey captures data from cancer survivors who previously received help accessing or paying for care from PAF and may not be representative of the larger cancer patient population.”

2. Did you collect any information on time since treatment or diagnosis, or on the respondents' current healthcare use/needs? If so, please report; if not, please note as a limitation, as these factors, particularly current healthcare needs, may influence one's difficulty paying for healthcare use.

Response: We agree that both time since diagnosis and current healthcare use or needs could influence payment for both healthcare and non-healthcare needs. However, the survey data used for this study was collected by Patient Advocate Foundation for administrative and programmatic purposes. Our analyses were thus limited by the use of secondary data. We have added this to our limitations section.

“Information potentially associated with both health insurance coverage and challenges paying for healthcare and non-healthcare needs, such as time since cancer diagnosis, current health care use or needs, and more detailed demographic information, was limited by use of secondary data.”

3. Please provide more detail on how your outcomes of interest were measured? Were these yes/no questions, or did you use a scale? If the latter, provide detail on how the scale was dichotomized.

Response: Respondents reported challenges paying for healthcare and non-healthcare needs using the single-item survey question, “Have you had trouble paying for any of the following since the beginning of the COVID-19 pandemic?” Respondents were then asked to select all that applied, which included food, household supplies, housing (rent or mortgage), utilities, phone, internet/data, car/gas/transportation, childcare/eldercare/home health services, and healthcare/medical costs (prescription medications, doctor’s visits, clinical/hospital services, medical supplies, etc.). We have added these details to our methods section.

4. Was age collected as a continuous variable, or was it collected in the categories reported in Table 1? If the former, consider revising your categorizations more meaningfully to reflect age 65 as the age of Medicare eligibility and 18-39 as the NCI's definition of young adult. Similarly, how was the income threshold of $48K determined?

Response: Age data was captured using the categories reported in Table 1, which again points to limitations presented by use of secondary data. We have added this to our limitations section.

“Information potentially associated with health insurance coverage and challenges paying for healthcare and non-healthcare needs, such as time since cancer diagnosis, current health care use or needs, and more detailed demographic information, was limited by use of secondary data.”

The income data in our study, which was also collected categorically, naturally fell into quartiles. To better understand potential differences between respondents with higher and lower household incomes, we dichotomized this data into those who had annual household incomes above and below the third quartile of income data. This translated to those an annual household income of < $48,000 (74% of our sample) compared to ≥ $48,000 (25% of our sample). Detailed income data is included in the table below.

Annual household income n %

≤ $23,999 486 33.6

$24,000-$47,999 582 40.2

$48,000-$71,999 223 15.4

$72,000-$95,999 74 5.1

$96,000-$119,999 13 0.9

≥ $120,000 52 3.6

Unknown 17 1.2

Thanks again for your consideration.

Sincerely,

Courtney P. Williams, DrPH

Postdoctoral Fellow

Attachment

Submitted filename: Response to Reviewers.docx

Click here for additional data file. (53.5KB, docx)

Decision Letter 1

Raymond Nienchen Kuo

26 Jul 2022

Health insurance and financial hardship in cancer survivors during the COVID-19 pandemic

PONE-D-21-32975R1

Dear Dr. Williams,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Raymond Nienchen Kuo, Ph.D

Academic Editor

PLOS ONE

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I am satisfied with responses from the authors. I have no further questions for the authors. Well done.

Reviewer #2: Thank you for your attention to addressing my previous comments and those of the other reviewer. I have no additional comments.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Christopher J. Longo

Reviewer #2: No

**********

Acceptance letter

Raymond Nienchen Kuo

28 Jul 2022

PONE-D-21-32975R1

Health insurance and financial hardship in cancer survivors during the COVID-19 pandemic

Dear Dr. Williams:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Professor Raymond Nienchen Kuo

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Table. Non-respondent sociodemographic characteristics (N = 11,749).

    (DOCX)

    Click here for additional data file. (14.5KB, docx)
    S2 Table. Adjusted model results estimating relative risk of trouble paying for non-healthcare necessities in under-resourced cancer survivors (N = 1,437).

    (DOCX)

    Click here for additional data file. (27.9KB, docx)
    Attachment

    Submitted filename: Response to Reviewers.docx

    Click here for additional data file. (53.5KB, docx)

    Data Availability Statement

    Data that support the findings of this study was collected for organizational and programmatic purposes by Patient Advocate Foundation and may be available upon request. Participants of this study did not agree for their data to be shared publicly. Use of data from Patient Advocate Foundation for analytic purposes requires a data use agreement that is reviewed by the external compliance officer prior to signature by both parties. Please contact PAF Compliance Officer Stephanie Trunk (Stephanie.trunk@patientadvocate.org) with inquiries.

    Articles from PLoS ONE are provided here courtesy of PLOS

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