Many cancer survivors experience challenges related to employment, including limitations in ability to work.1 Given that most health insurance coverage for working-age individuals in the US is employer-based, a challenge is the inability to freely leave a job given limitations on health insurance portability, also called job lock.2 Job lock can negatively affect career trajectory and quality of life.3 Likewise, spouse/partner job lock can also affect family well-being.4 We examined job lock prevalence among cancer survivors and their spouses/partners and associated factors in the US.
Methods
This study identified cancer survivors who responded to questions about job lock (ever having stayed at a job out of concern for losing health insurance) from the 2011, 2016, and 2017 Medical Expenditure Panel Survey Experiences With Cancer questionnaire. Separate multivariable logistic regression models examined the association of job lock in survivors and spouses/partners with self-reported survivor characteristics, including current age, sex, educational attainment, race/ethnicity, years since last cancer treatment, current marital status, comorbidities, and household income as a percentage of the federal poverty level (FPL). The study was determined to be exempt from institutional review by the National Cancer Institute. Weighted logistic regression modeling was used. P-values were determined to be significant at 0.05 (two-tailed test). Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines were used. Analyses were conducted using SAS version 9.4 (SAS Institute) and SAS-callable SUDAAN version 11.0.0 (RTI International).
Results
Of 1340 survivors, 526 (42.2%) were men and 814 (57.8%) were women. There were 365 respondents (26.1%) between the ages of 18 and 54 years, 387 (29.6%) between 55 and 64 years, 389 (30.1%) between 65 and 74 years, and 199 (14.4%) older than 75 years. Of 1340 surveyed cancer survivors overall, 266 (19.6%) (95% CI, 17.1%-22.3%) reported job lock. Of 1593 partners of survivors, 677 (44.4%) were men and 916 (55.6%) were women. There were 320 (18.9%) respondents between the ages of 18 and 54 years, 372 (24.0%) between 55 and 64 years, 475 (31.2%) between 65 and 74 years, and 426 (25.9%) older than 75 years. Of 1593 spouses/partners surveyed, 171 (10.7%) (95% CI, 8.4%-11.9%) reported job lock. Of 1094 respondents, 374 (32.3%) (95% CI, 29.1%-35.6%) reported any job lock for either themselves or their spouse/partner. Of 628 women, 235 (35.9%) (95% CI, 31.7%-40.3%, 235/628) reported any job lock and of 466 men, 139 (27.9%) (95% CI, 23.5%-32.8%) reported any job lock (Figure).
Characteristics significantly associated with survivor job lock included younger age and earning income between 138% and 400% of the FPL (Table). Spouse/partner job lock was more common among survivors who were women vs men (12% vs 8%), married vs unmarried (11% vs 7%), and nonwhite vs non-Hispanic white (16% vs 9%). Survivors with 3 or more vs no comorbidities were more likely to report spouse/partner job lock (14% vs 6%). Younger survivors (under 75 years) were more likely to report spouse/partner job lock, as were those earning between 138% and 400% of the FPL.
Discussion
In this study, approximately 1 in 3 cancer survivors in the US reported job lock for themselves or their spouses/partners, suggesting that job lock is common and has implications for the well-being and careers of both survivors and their families. Given higher prevalence of job lock among younger survivors and those with incomes near the poverty level, it is important to note that those earning between 138% and 400% of the FPL are ineligible for Medicaid and may have fewer employment alternatives with comprehensive health benefits. Clinicians, social workers, and navigators have opportunities to identify job lock and other employment concerns throughout treatment/survivorship care and connect survivors with employment and health insurance counseling.5
One long-term study of childhood cancer survivors from 20186 found that 23% of survivors reported job lock. The present study demonstrates consistent findings in a nationally representative population of adult cancer survivors and also provides data on the prevalence of spousal/partner job lock. The Patient Protection and Affordable Care Act eliminated preexisting condition exclusions and created Marketplace exchanges for purchasing insurance coverage outside of work; whether these provisions will reduce job lock over time is unknown.
Study limitations include the cross-sectional design, lack of a control group, self-report of measures, and lack of information on cancer stage or course of treatment. Response rates ranged from 44% to 55%, comparable with other national household surveys. Sample weights help address nonresponse. Study strengths include it being a large, nationally representative sample and assessment of job lock experiences.
The present study found that 32% of cancer survivors reported job lock in either themselves or their spouses/partners. Additional research, particularly prospective, longitudinal, and qualitative studies, can help elucidate downstream consequences that may vary by sex and develop interventions to increase availability of insurance coverage regardless of employment.
Published Online: April 23, 2020. doi:10.1001/jamaoncol.2020.0742
Concept and design: Kent, deMoor, Zhao, Ekwueme, Yabroff.
Acquisition, analysis, or interpretation of data: Kent, deMoor, Ekwueme, Han, Yabroff.
Drafting of the manuscript: Kent, deMoor, Ekwueme, Yabroff.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Kent, Ekwueme, Yabroff.
Administrative, technical, or material support: Kent, Zhao.
Supervision: Kent.
Conflict of Interest Disclosures: None reported.
Funding/Support: Drs Han and Zhao received funding from AstraZeneca unrelated to this study.
Role of the Funder/Sponsor: AztraZeneca had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The findings and conclusions in this article represent those of the authors and do not necessarily represent the official position of the National Cancer Institute, National Institutes of Health, the US Centers for Disease Control & Prevention, or the American Cancer Society.
References
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