An Intersectional Analysis of Behavioral Financial Hardship and Healthcare Utilization among LGBTQ+ Cancer Survivors

Abstract

Background lesbian, gay, bisexual, transgender, queer, or another non-heterosexual or cisgender identity (LGBTQ+) cancer survivors experience high financial hardship. However, structural drivers of inequities do not impact all LGBTQ+ individuals equally. Using All of Us data, we conducted an intersectional analysis of behavioral financial hardship among LGBTQ+ cancer survivors. Methods LGBTQ+ inequities in behavioral financial hardship (ie, cost-related foregone care, delayed care, and medication alterations) and non-cost-related delayed care were estimated using All of Us Data. Multivariable logit models were used to generate predicted probabilities, average marginal effects (AME), and 95% confidence intervals. Models were then used to estimate inequities when disaggregating LGBTQ+ status and combing LGBTQ+ status with age, race, ethnicity, and treatment status. Results This analysis included N = 36,217 cancer survivors (6.6%, n = 2,399 LGBTQ+). In multivariable models, LGBTQ+ identity was associated with higher probabilities of and significant AME for all types of behavioral financial hardship (foregone care 31.1% vs. 19.4%; delayed care 22.6% vs. 15.6%; medication alterations 19.2% vs. 11.9%) and non-cost delayed care (14.3% vs. 7.2%). Within the disaggregated analysis, cisgender bisexual and another/multiple orientation women and gender minority survivors had the highest predicted probabilities of all outcomes. In intersectional analyses, survivors who were aged 18-39 and LGBTQ+, Black and LGBTQ+, or Hispanic/Latine and LGBTQ+ had the highest predicted probabilities of all outcomes. Conclusions LGBTQ+ cancer survivors experience significantly more behavioral financial hardship and non-cost-related delayed care then non-LGBTQ+ cancer survivors. Interventions at the individual, system, and policy level are needed to address LGBTQ+ inequities in financial hardship.