Relationships Among Health Insurance Literacy, Financial Toxicity, and Sociodemographic Factors in Patients With Cancer

PURPOSE The objective of the study was to describe the prevalence of health insurance literacy (HIL) and investigate how patient-reported outcome measures assessing HIL are related to financial toxicity in patients with cancer. METHODS We assessed HIL and financial toxicity in 404 patients enrolled between December 2019 and January 2021 at two medical centers in the United States. We conducted exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) to explore and test the relationships among the factors and items. We fit structural equation models (SEMs) to find the relationships among the factors and sociodemographic/clinical characteristics. RESULTS The EFA revealed items loaded on four factors: knowledge about health insurance, confidence related to HIL (HIL confidence), information-seeking behavior related to health insurance, and financial toxicity. The four-factor CFA model had good fit statistics (comparative fit index, 0.960; Tucker-Lewis index, 0.958; root mean square error of approximation, 0.046; and standardized root mean square residual, 0.086). In SEM, income, education level, and race positively predicted knowledge about health insurance. Knowledge about health insurance and number of total lines of cancer treatment was positively associated with HIL confidence. Higher income, older age, and HIL confidence were associated with less financial toxicity. Higher levels of financial toxicity, HIL confidence, and knowledge were associated with greater information-seeking behavior. CONCLUSION Our findings showed how different aspects of HIL are related to financial toxicity even after adjustment for sociodemographic and clinical characteristics. Future studies should investigate the longitudinal relationships among these factors to help develop interventions to mitigate financial toxicity. CONTEXT Key Objective How do questionnaire items measuring financial toxicity and health insurance literacy (HIL) cluster together to define constructs, and how is financial toxicity construct explained in relation to health insurance knowledge and literacy? Knowledge Generated Financial toxicity is directly and indirectly related to HIL and is, in turn, related to information-seeking behavior. We also found from exploratory factor analysis and confirmatory factor analysis that individual items were loading on four factors in the expected way, confirming structural validity of the questionnaires. Relevance Financial toxicity experienced by not only patients but also their families should be assessed, and the benefits we found in information-seeking show that we should consider ways to facilitate information-seeking and develop confidence related to choosing and using health insurance.