title: Health insurance coverage, care accessibility and affordability for adult survivors of childhood cancer: a cross-sectional study of a nationally representative database.
abstract: We describe national patterns of health insurance coverage and care accessibility and affordability in a national sample of adult childhood cancer survivors (CCS) compared to adults without cancer.
  
  
  
  Using data from the 2010-2014 National Health Interview Survey (NHIS), we selected a sample of all CCS age 21 to 65 years old and a 1:3 matched sample of controls without a history of cancer. We examined insurance coverage, care accessibility and affordability in CCS and controls. We tested for differences in the groups in bivariate analyses and multivariable logistic regression models.
  
  
  
  Of all respondents age 21-65 in the full NHIS sample, 443 (0.35 %) were CCS. Fewer CCS were insured (76.4 %) compared to controls (81.4 %, p = 0.067). Significantly more CCS reported delaying medical care (24.7 vs 13.0 %), needing but not getting medical care in the previous 12 months (20.0 vs 10.0 %), and having trouble paying medical bills (40.3 vs 19.7 %) compared to controls (p < 0.0001 for all). More CCS reported trouble with care affordability in the previous 12 months compared to controls on six categories of care and for a combined measure of affordability (p < 0.0001 for composite of all). Adjusted analyses demonstrated that these differences comparing CCS to controls remained significant.
  
  
  
  CCS report problems with health care accessibility and affordability. These analyses support the development of policies to assure that CCS have access to affordable services.
  
  
  
  Efforts to improve access to high-quality and affordable insurance for CCS may help reduce the gaps in getting medical care and problems with affordability. Health care providers should be aware that such problems exist and should discuss affordability and ability to obtain care with patients.
authors.affiliation: Department of Pediatrics, Massachusetts General Hospital (MGH), and Harvard Medical School (HMS), 125 Nashua Street, Suite 860, Boston, MA, 01224, USA. kkuhlthau@mgh.harvard.edu.
authors.forename: Karen A
authors.initials: KA
authors.lastname: Kuhlthau
authors.affiliation: Clinical Fellow in Oncology, MGH Cancer Center, Yawkey 10B, Boston, MA, 02114, USA.
authors.forename: Ryan D
authors.initials: RD
authors.lastname: Nipp
authors.affiliation: MGH Biostatistics Center, 50 Staniford Street, Suite 560, Boston, MA, 02114, USA.
authors.forename: Amy
authors.initials: A
authors.lastname: Shui
authors.affiliation: Department of Medicine, Columbia University Medical Center, 180 Fort Washington Avenue Room 924, New York, NY, 10032, USA.
authors.forename: Sean
authors.initials: S
authors.lastname: Srichankij
authors.affiliation: Department of Pediatric Hematology/Oncology, Huntsman Cancer Institute, 2000 Circle of Hope, Room 4145, Salt Lake City, UT, 84112, USA.
authors.forename: Anne C
authors.initials: AC
authors.lastname: Kirchhoff
authors.affiliation: HMS and Harvard Pilgrim Health Care Institute, Department of Population Medicine, Landmark Center, 401 Park Drive Suite 401, Boston, MA, 02215, USA.
authors.forename: Alison A
authors.initials: AA
authors.lastname: Galbraith
authors.affiliation: Department of Psychiatry, MGH and HMS, 50 Staniford Street, Room 907, Boston, MA, 02114, USA.
authors.forename: Elyse R
authors.initials: ER
authors.lastname: Park
mesh_terms: D000328:Adult; D000368:Aged; D003430:Cross-Sectional Studies; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D019458:Insurance Coverage / Q000706:statistics & numerical data*; D007348:Insurance, Health / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000628:therapy*; D017741:Survivors; D055815:Young Adult
keywords: Access; Affordability; Childhood cancer survivors; Insurance; Pediatric; Survivorship