Higher Out-of-Pocket Cost Burden Linked to Care Avoidance in All Adults

Adults who spend a larger share of their household income on out-of-pocket health care costs are more likely to forgo needed medical care because of cost, according to a new analysis published in Cancer—and this pattern holds true whether or not a person has a history of cancer.¹

The retrospective, cross-sectional study drew on data from 5 waves (2015-2024) of the Understanding America Study, a probability-based internet panel maintained by the University of Southern California. Researchers analyzed 21,299 survey responses from 10,811 adults, including 2180 responses from 1052 respondents with a history of cancer and 19,119 responses from 9759 respondents without cancer.

Key Findings

After adjustment for demographic, socioeconomic, and comorbidity characteristics, each 1% increase in out-of-pocket costs relative to household income (OOP:HHI) was associated with 3% higher odds of cost-related care avoidance (adjusted OR, 1.03; 95% CI, 1.02-1.04).

In unadjusted analyses, this association appeared weaker among respondents with a history of cancer than among those without, but the interaction was no longer statistically significant once other respondent characteristics were accounted for (P =.41 in the multivariable model, vs P =.001 unadjusted).

The proportion of responses indicating cost-related care avoidance was numerically higher among those without cancer history (15.9%) than those with cancer history (11.2%). However, within each subgroup, the likelihood of avoidance rose sharply once OOP:HHI exceeded conventional catastrophic-expenditure thresholds of 10%, 25%, or 40%. Among respondents with cancer history, for example, 9.5% reported care avoidance below the 10% OOP:HHI threshold, compared with 44.1% above it.

Investigators also compared how well OOP:HHI performed as a standalone predictor of care avoidance against a multivariable model that incorporated sociodemographic and clinical characteristics. OOP:HHI alone showed only modest discrimination; the multivariable model performed substantially better, with sensitivity and specificity of 94% and 93%, respectively.

Implications: Comprehensive Risk Assessments Needed

Out-of-pocket costs are widely recognized as a marker of underinsurance when they begin to affect patient well-being, treatment decisions, or outcomes; these consequences are commonly referred to as financial toxicity.² Although the retrospective, observational nature of the study precludes causal inference and relied on self-reported survey data, the findings suggest that financial burden remains an important barrier to health care access regardless of cancer history.

The investigators noted that while OOP:HHI was independently associated with cost-related care avoidance, it performed best when combined with demographic, socioeconomic, and clinical factors, highlighting the value of a more comprehensive approach to identifying patients at risk of financial toxicity. For oncology practices, incorporating measures of out-of-pocket cost burden alongside routinely collected clinical and sociodemographic data could help identify patients at elevated risk for financial toxicity and facilitate earlier supportive interventions, though further prospective validation is needed.

“Together, these findings support developing system-level risk-stratification tools that integrate OOP:HHI with routinely collected patient characteristics to proactively identify individuals at risk of financial toxicity and guide targeted interventions,” authors Liang et al concluded.¹

Financial Toxicity: The Systemic Toll of Cancer Care

REFERENCES

1. Liang X, Tay D, Ke Y, et al. Comparing the association between out-of-pocket cost burden and cost-related care avoidance among individuals with and without a history of cancer. Cancer. 2026;e70495. doi:10.1002/cncr.70495

2. Zafar SY, Peppercorn JM, Schrag D, et al. The financial toxicity of cancer treatment: a pilot study assessing out-of-pocket expenses and the insured cancer patient's experience. Oncologist. 2013;18(4):381-390. doi:10.1634/theoncologist.2012-0279