Association of Financial Worry and Material Financial Risk with Short-Term Ambulatory Healthcare Utilization in a Sample of Subsidized Exchange Patients



Financial burden can affect healthcare utilization. Few studies have assessed the short-term associations between material (debt, trouble paying rent) and psychological (worry or distress about affording future healthcare) financial risks, and subsequent outpatient and emergency healthcare use. Worry was defined as concerns about affording future healthcare.


Examine whether worry about affording healthcare is associated with healthcare utilization when controlling for material risk and general anxiety


Longitudinal observational study


Kaiser Permanente members with exchange-based federally subsidized health insurance (n = 450, 45% response rate)

Main Measures

Survey measures of financial risks (material difficulty paying for medical care and worry about affording healthcare) and general anxiety. Healthcare use (primary care, urgent care, emergency department, and outpatient specialty visits) in the 6 months following survey completion.

Key Results

Emergency department and primary care visits were not associated with material risk, worry about affording care, or general anxiety in individual and pooled analyses (all 95% confidence intervals (CI) for relative risk (RR) included 1). Although no individual predictor was associated with urgent care use (all 95% CIs for RR included 1), worry about affording prescriptions (relative risk (RR) = 2.01; 95% CI 1.14, 3.55) and general anxiety (RR = 0.38; 95% CI 0.15, 0.95) were significant when included in the same model, suggesting the two confounded each other. Worry about affording healthcare services was associated with fewer specialty care visits (RR = 0.40; 95% CI 0.25, 0.64) even when controlling for material risk and general anxiety, although general anxiety was also associated with more specialty care visits (RR = 1.98; 95% CI, 1.23, 3.18).


Screening for both general anxiety and financial worry may assist with specialty care utilization. Identifying these concerns may provide more opportunities to assist patients. Future research should examine interventions to reduce worry about cost of care.

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  1. 1.

    Irwin A, Valentine N, Brown C, et al. The commission on social determinants of health: Tackling the social roots of health inequities. Plos Medicine. 2006;3(6):749-751.

    Article  Google Scholar 

  2. 2.

    Heiman HJ, Artiga S. Beyond health care: The role of social determinants in promoting health and health equity. Kaiser Family Foundation;2015.

  3. 3.

    Goldstein D, Holmes J. 2011 Physicians' Daily Life Report. Robert Wood Johnson Foundation;2011.

  4. 4.

    Kennedy BP, Kawachi I, Glass R, Prothrow-Stith D. Income distribution, socioeconomic status, and self rated health in the United States: multilevel analysis. BMJ. 1998;317(7163):917-921.

    CAS  Article  Google Scholar 

  5. 5.

    Xiao Q, Berrigan D, Matthews CE. A prospective investigation of neighborhood socioeconomic deprivation and self-rated health in a large US cohort. Health Place. 2017;44:70-76.

    Article  Google Scholar 

  6. 6.

    Ota A, Yatsuya H, Nishi N, et al. Relationships among Socioeconomic Factors and Self-rated Health in Japanese Adults: NIPPON DATA2010. J Epidemiol. 2018;28 Suppl 3:S66-S72.

    Article  Google Scholar 

  7. 7.

    Sulander T, Pohjolainen P, Karvinen E. Self-rated health (SRH) and socioeconomic position (SEP) among urban home-dwelling older adults. Arch Gerontol Geriatr. 2012;54(1):117-120.

    Article  Google Scholar 

  8. 8.

    Koch CG, Li L, Kaplan GA, et al. Socioeconomic Position, Not Race, Is Linked to Death After Cardiac Surgery. Circulation: Cardiovascular Quality and Outcomes. 2010;3(3):267-276.

    Google Scholar 

  9. 9.

    Valtorta NK, Hanratty B. Socioeconomic variation in the financial consequences of ill health for older people with chronic diseases: a systematic review. Maturitas. 2013;74(4):313-333.

    Article  Google Scholar 

  10. 10.

    Yabroff KR, Dowling EC, Guy GP, et al. Financial Hardship Associated With Cancer in the United States: Findings From a Population-Based Sample of Adult Cancer Survivors. J Clin Oncol. 2016;34(3):259-267.

    Article  Google Scholar 

  11. 11.

    Altice CK, Banegas MP, Tucker-Seeley RD, Yabroff KR. Financial Hardships Experienced by Cancer Survivors: A Systematic Review. J Natl Cancer Inst. 2017;109(2).

  12. 12.

    Gordon LG, Merollini KMD, Lowe A, Chan RJ. A Systematic Review of Financial Toxicity Among Cancer Survivors: We Can't Pay the Co-Pay. Patient. 2017;10(3):295-309.

    Article  Google Scholar 

  13. 13.

    Bestvina CM, Zullig LL, Rushing C, et al. Patient-oncologist cost communication, financial distress, and medication adherence. J Oncol Pract. 2014;10(3):162-167.

    Article  Google Scholar 

  14. 14.

    Zullig LL, Peppercorn JM, Schrag D, et al. Financial Distress, Use of Cost-Coping Strategies, and Adherence to Prescription Medication Among Patients With Cancer. J Oncol Pract. 2013;9(6S):60s-63s.

    Article  Google Scholar 

  15. 15.

    Khera N, Chang YH, Hashmi S, et al. Financial burden in recipients of allogeneic hematopoietic cell transplantation. Biol Blood Marrow Transplant. 2014;20(9):1375-1381.

    Article  Google Scholar 

  16. 16.

    Jones S, Du YX, Panattoni L, Henrikson N. Development of a questionnaire to assess worry about affording healthcare in an international sample. Qual Life Res. 2019;28:S54-S54.

    Google Scholar 

  17. 17.

    Jones SMW, Walker R, Fujii M, Nekhlyudov L, Rabin BA, Chubak J. Financial difficulty, worry about affording care, and benefit finding in long-term survivors of cancer. Psychooncology. 2018;27(4):1320-1326.

    Article  Google Scholar 

  18. 18.

    Berggren U. General and specific fears in referred and self-referred adult patients with extreme dental anxiety. Behav Res Ther. 1992;30(4):395-401.

    CAS  Article  Google Scholar 

  19. 19.

    Buss C, Davis EP, Hobel CJ, Sandman CA. Maternal pregnancy-specific anxiety is associated with child executive function at 6-9 years age. Stress. 2011;14(6):665-676.

    CAS  Article  Google Scholar 

  20. 20.

    Reck C, Zimmer K, Dubber S, Zipser B, Schlehe B, Gawlik S. The influence of general anxiety and childbirth-specific anxiety on birth outcome. Arch Womens Ment Health. 2013;16(5):363-369.

    CAS  Article  Google Scholar 

  21. 21.

    Eastin MS, Guinsler NM. Worried and wired: effects of health anxiety on information-seeking and health care utilization behaviors. Cyberpsychol Behav. 2006;9(4):494-498.

    Article  Google Scholar 

  22. 22.

    Norris L. Will you receive an Obamacare premium subsidy? How the Affordable Care Act's subsidies are calculated, and who is eligible to receive them. Published 2018. Accessed June 1, 2019.

  23. 23.

    Collins SR, Bhupal HK, Doty MM. Health insurance coverage eight years after the ACA. The Commonwealth Fund. Published 2019. Accessed.

  24. 24.

    Barlow DH. Anxiety and its disorders: The nature and treatment of anxiety and panic. 2nd ed. New York: The Guilford Press; 2004.

    Google Scholar 

  25. 25.

    Jones SM, Amtmann D. Differential item function analysis of a scale measuring worry about affording healthcare in multiple sclerosis. Rehabil Psychol. 2016;61(4):430-434.

    Article  Google Scholar 

  26. 26.

    Jones SM, Amtmann D. Health care worry is associated with worse outcomes in multiple sclerosis. Rehabil Psychol. 2014;59(3):354-359.

    Article  Google Scholar 

  27. 27.

    LaForge K, Gold R, Cottrell E, et al. How 6 Organizations Developed Tools and Processes for Social Determinants of Health Screening in Primary Care: An Overview. The Journal of ambulatory care management. 2018;41(1):2-14.

    Article  Google Scholar 

  28. 28.

    Adler NE, Stead WW. Patients in context--EHR capture of social and behavioral determinants of health. N Engl J Med. 2015;372(8):698-701.

    CAS  Article  Google Scholar 

  29. 29.

    Puterman E, Haritatos J, Adler NE, Sidney S, Schwartz JE, Epel ES. Indirect effect of financial strain on daily cortisol output through daily negative to positive affect index in the Coronary Artery Risk Development in Young Adults Study. Psychoneuroendocrinology. 2013;38(12):2883-2889.

    CAS  Article  Google Scholar 

  30. 30.

    Hall MH, Matthews KA, Kravitz HM, et al. Race and financial strain are independent correlates of sleep in midlife women: the SWAN sleep study. Sleep. 2009;32(1):73-82.

    PubMed  PubMed Central  Google Scholar 

  31. 31.

    Lowe B, Wahl I, Rose M, et al. A 4-item measure of depression and anxiety: validation and standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population. J Affect Disord. 2010;122(1-2):86-95.

    Article  Google Scholar 

  32. 32.

    Zeger SL, Liang KY, Albert PS. Models for longitudinal data: a generalized estimating equation approach. Biometrics. 1988;44(4):1049-1060.

    CAS  Article  Google Scholar 

  33. 33.

    Lesaffre E, Marx BD. Collinearity in Generalized Linear-Regression. Commun Stat-Theor M. 1993;22(7):1933-1952.

    Article  Google Scholar 

  34. 34.

    Lewis CC, Wellman R, Jones SMW, et al. Comparing the performance of two social risk screening tools in a vulnerable subpopulation. Journal of Family Medicine and Primary Care. In press.

  35. 35.

    Horst P. The role of predictor variables which are independent of the criterion. Social Science Research Council. 1941;48:431-436.

    Google Scholar 

  36. 36.

    Jones SMW, Litwin P. Association of healthcare utilization with financial worry and anxiety in a general population sample. Psychol Health Med. 2020:1-8.

  37. 37.

    Collins JM, Olive P, O'Rourke CM. Financial Coaching's Potential for Enhancing Family Financial Security. Journal of Extension. 2013;51(1).

  38. 38.

    Shankaran V, Leahy T, Steelquist J, et al. Pilot Feasibility Study of an Oncology Financial Navigation Program. J Oncol Pract. 2018;14(2):e122-e129.

    Article  Google Scholar 

  39. 39.

    Henrikson NB, Tuzzio L, Loggers ET, Miyoshi J, Buist DS. Patient and oncologist discussions about cancer care costs. Support Care Cancer. 2014;22(4):961-967.

    Article  Google Scholar 

  40. 40.

    Pinto AD, Bondy M, Rucchetto A, Ihnat J, Kaufman A. Screening for poverty and intervening in a primary care setting: an acceptability and feasibility study. Fam Pract. 2019;36(5):634-638.

    Article  Google Scholar 

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The authors would like to thank the staff of Kaiser Permanente Washington, Southern California, and Colorado for contributing to this project.


Funding was provided by the Kaiser Foundation.

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Correspondence to Salene M. W. Jones PhD, MA.

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Jones, S.M.W., Banegas, M.P., Steiner, J.F. et al. Association of Financial Worry and Material Financial Risk with Short-Term Ambulatory Healthcare Utilization in a Sample of Subsidized Exchange Patients. J GEN INTERN MED (2021).

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  • economic well-being
  • financial toxicity
  • financial burden
  • financial hardship