Healthcare affordability among adults with liver disease from 2004-2018 in the United States: a national cohort study

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Content 2023 Ayyala-Somayajula, Divya
Healthcare Affordability among Adults with Liver Disease from 2004-2018 in the United States:
A National Cohort Study
By
Divya Ayyala-Somayajula
A Thesis Presented to the
FACULTY OF THE USC KECK SCHOOL OF MEDICINE
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements of the Degree
MASTER OF SCIENCE
(CLINICAL AND BIOMEDICAL INVESTIGATIONS)
May 2023

ii
TABLE OF CONTENTS
List of Tables..................................................................................................................................v
List of Figures.................................................................................................................................vi
Abstract ........................................................................................................................................ vii
Chapter 1: Introduction……........................................................................................................... 1
Chapter 2: Methods……................................................................................................................. 3
Chapter 3: Results……..................................................................................................................11
Chapter 4: Discussion……............................................................................................................22
Bibliography…..............................................................................................................................29
Appendices.....................................................................................................................................33
Appendix A: Supplementary Tables..............................................................................................36
Supplemental Table 1. Univariable model of healthcare affordability and accessibility
issues in adults with liver disease vs no liver disease……….…………………...…………..…..36

Supplemental Table 2. Univariable model of healthcare affordability and accessibility
issues in those with liver disease vs history of cancer……….…………………...……………..37

Supplemental Table 3. Univariable model of healthcare affordability and accessibility
issues in those with liver disease vs emphysema……….…………………...…………….....…..38

Supplemental Table 4. Univariable model of healthcare affordability and accessibility
issues in those with liver disease vs coronary artery disease……….…………………...……....39

Supplemental Table 5. Univariable model of healthcare affordability in adults with
liver disease by service type…………………………….…………….……………………...….40

Supplemental Table 6. Multivariable model of healthcare affordability issues in
adults with liver disease vs no liver disease……….……………...……………...…………..…..42

Supplemental Table 7. Multivariable model of healthcare affordability issues in
adults with liver disease vs history of cancer……….………………….………...…………..…..43

Supplemental Table 8. Multivariable model of healthcare affordability issues in
adults with liver disease vs emphysema……….…………………...………………………..…..44

Supplemental Table 9. Multivariable model of healthcare affordability issues in
adults with liver disease vs coronary artery disease……….………………….....…………..…..45

Supplemental Table 10. Multivariable model of healthcare affordability issues in
adults with liver disease vs no liver disease by service type……….……….…...…………..…..46

iii

Supplemental Table 11. Multivariable model of healthcare affordability issues in
adults with liver disease (expanded definition) vs no liver disease……………...…………..…..48

Supplemental Table 12. Post Hoc Analysis: Multivariable model of healthcare
affordability and accessibility issues in adults with liver disease vs liver disease
adjusted race……….…………………………………………………...………...…………..…..49

Supplemental Table 13. Post Hoc Analysis: Multivariable model of healthcare
affordability and accessibility issues in adults with liver disease vs liver disease
adjusted for key medical comorbidities..………… …..................................................................50

Supplemental Table 14. Post Hoc Analysis: Multivariable model of healthcare
affordability and accessibility issues in adults with liver disease vs history of cancer
adjusted for key medical comorbidities..………...........................................................................52

Supplemental Table 15. Post Hoc Analysis: Multivariable model of healthcare
affordability and accessibility issues in adults with liver disease vs emphysema
adjusted for key medical comorbidities..…….………..................................................................54

Supplemental Table 16. Post Hoc Analysis: Multivariable model of healthcare
affordability and accessibility issues in adults with liver disease vs coronary artery disease
adjusted for key medical comorbidities………………………………………………………….56

Supplemental Table 17. Cox regression hazards models of the effects of financial
toxicity on mortality among patients with liver disease…………………………………...…… 55

Supplemental Table 18. Cox regression hazards models of the effects of affordability
of medical services on mortality among patients with liver disease……………………..………58

Supplemental Table 19. Cox regression hazards models of the effects of delayed
care on mortality among patients with liver disease………………………………...….………..59

Supplemental Table 20. Cox regression hazards models of the effects of needing
but not getting care on mortality among patients with liver disease……………………………..60

Supplemental Table 21. Cox regression hazards models of the effects of needing
but not getting care on mortality among patients with liver disease…………..……………...…61

Supplemental Table 22. Types of cancers reported by participants from 2004-2018…………...62

Appendix B: Supplementary Figures............................................................................................ 64

Supplemental Figure 1. Age adjusted proportion of adults reporting financial stress
from 2004-2018 by medical service type……………..…………………………....……….……64

iv
Supplemental Figure 2. Kaplan Meier all-cause mortality in adults with liver
disease by financial distress status.......................................…………………………………..…65

v
List of Tables

Table 1: Baseline Characteristics ..................................................................................................10

Table 2: Multivariable model of healthcare affordability and accessibility issues in
adults with liver disease vs no liver disease or other chronic diseases..........................................17

Table 3: Multivariable model of risk factors associated with healthcare affordability
and accessibility amongst adults with liver disease.......................................................................18

Table 4: Cox regression hazards model of the effects of financial distress^ on
mortality among patients with liver disease...................................................................................20

vi
List of Figures
Figure 1: Consort Diagram............................................................................................................35

Figure 2: Age-adjusted proportion of adults reporting healthcare affordability issues
from 2004-2018 in adults with and without liver disease..............................................................13

Figure 3: Age-adjusted proportion of adults reporting healthcare affordability issues
from 2004-2018 in adults with liver disease, coronary artery disease, emphysema,
and history of cancer......................................................................................................................14

vii
Abstract
Background&Aims: Liver disease carries substantial morbidity and mortality, likely incurring
financial distress (ie, healthcare affordability and accessibility issues), though long-term
national-level data are limited.
Methods: Using the National Health Interview Survey from 2004-2018, we categorized adults
based on report of liver disease and other chronic conditions linked to mortality data from the
National Death Index. We estimated age-adjusted proportions of adults reporting healthcare
affordability and accessibility issues. Multivariable logistic regression and cox regression
assessed the association of liver disease with financial distress and financial distress with all-
cause mortality, respectively.
Results: Among adults with liver disease (N=8,977) vs without liver disease (N=1,006,782); vs
cancer history (N=38,570); vs coronary artery disease (N=21,510), the age-adjusted proportion
reporting healthcare affordability issues was more common in adults with liver disease [medical
services: 36.9% (95% CI: 36.7-37.0) vs 18.3% (18.2-18.5); 27.0% (26.8-27.2); 31.8% (31.6%-
31.9%); medication: 20.4% (20.3-20.5) vs 8.2% (8.1-8.3); 15.0% (14.9-15.1%); 20.5% (20.4%-
20.6%)] but not emphysema (N=7,937) [medical services: 43.2% (43.0%-43.3%); medication:
26.4% (26.2-26.5)]. In multivariable analysis, liver disease (vs without liver disease; vs cancer
history; vs coronary artery disease) was associated with increased likelihood of reporting
inability to afford medical services [aOR: 2.2 (2.1-2.4); 2.0 (1.7-2.3); 1.4 (1.3-1.5] and
medications [aOR: 2.4 (2.2-2.5); 1.6 (1.3-1.9); 1.2 (1.1-1.3)], delays in medical care [aOR: 2.1

viii
(2.0-2.3); 1.8 (1.5-2.1); 1.3 (1.2-1.4)], and not receiving needed medical care [aOR: 2.2 (2.0-2.4);
1.6 (1.3-1.9); 1.3 (1.1-1.4)] . In multivariable analysis, patients with liver disease (vs
emphysema), were more likely to report inability to afford medical services ([aOR: 1.1 (1.0-1.2)]
only. In multivariable analysis, among adults with liver disease, financial distress (vs. without
financial distress) was associated with increased all-cause mortality [aHR 1.1 (1.0-1.3)].
Conclusions: Adults with liver disease face greater financial distress than adults without liver
disease, cancer, and coronary artery disease. Financial distress is associated with increased risk
of all-cause mortality among adults with liver disease. Interventions to improve healthcare
affordability should be prioritized in this population.

1
Chapter One: Introduction
Chronic liver disease is the 11
th
leading cause of death worldwide accounting for 1.32 million
deaths in 2019
1
. In the United States (US), the prevalence of chronic liver disease has nearly
doubled over the past two decades with cirrhosis related mortality rising in parallel
2,3,4
.
Healthcare utilization for chronic liver disease has increased, including inpatient hospitalizations
for advanced chronic liver disease, infections and portal hypertensive complications
5-10
.
Healthcare expenditure, as a result, has increased with US healthcare spending totaling $32.5
billion dollars as of 2016
11
.

Increases in healthcare expenditure has translated into higher annual out of pocket costs for
adults with liver disease
7,12
. Medical debt among this population ranges from 24% to 46%, with
7%-8% filing for medical bankruptcy compared to 3% among adults with cancer history, a well-
described cohort who incur medical debt
13-15
. Consequently, adults with liver disease are 40%
more likely to experience hardship from medical bills (i.e. financial burden)
16,17
. To address
financial burden incurred from medical expenses, several studies have described tradeoffs in
medical care (i.e. financial distress
17
) such as medication nonadherence
18
, missing medical
appointments
13
, missing medical procedures
13
, or food insecurity
16
. These tradeoffs have resulted
in higher healthcare utilization, particularly in the inpatient and emergency room settings (i.e.
financial toxicity)
16
.

However, financial distress in adults with liver disease is not well studied on a national level.
Most data that exist are limited to single center studies with small sample sizes
13
. Such data are
prone to bias and may not be substantial enough to provide impetus for policy change. The few

2
studies that do utilize national databases include short study periods that limit the ability to
examine the impact of major legislation, such as the Affordable Care Act, which drastically
changed health insurance coverage in the US, particularly in low-income populations
7,16,18
.
Furthermore, the relationship between financial distress and mortality is lacking. Financial
distress has been shown in adults with cancer history and cardiovascular disease to be associated
with increased mortality
19,20
. Establishing and quantifying the degree of association between
financial distress and mortality among adults with liver disease would be useful to determine if
interventions to alleviate financial distress are needed and if they would be cost-effective.

In this study, we sought to quantify financial distress (healthcare affordability and accessibility
issues) in adults with liver disease compared to adults without liver disease and other chronic
diseases from 2004-2018 in a nationally-representative sample. We then sought to evaluate the
differential impact of financial distress on mortality, and identify demographic factors associated
with healthcare affordability and accessibility issues among adults with liver disease.

3
Chapter Two: Methods
Data sources
The National Health Interview Survey (NHIS) is conducted by the government US Census
Bureau, and is a nationally-representative annual, cross-sectional survey administered to
noninstitutionalized non-military individuals, which aggregates family, household, person, and
adult surveys. NHIS utilizes complex sampling to provide estimates representative of the entire
US population (https://www.cdc.gov/nchs/nhis/1997-2018.htm)
21
. Data were collected through
questionnaires with information regarding demographic characteristics, health conditions, and
socioeconomic factors at both a family and person level administered by trained interviewers in a
face-to-face format. The survey has been validated and used to assess issues of healthcare
affordability and access among other subspecialties
16,22,23,24
. We linked the individual-level data
from the NHIS to the National Death Index, which is a centralized national database of death
record information compiled by state governments, to obtain vital status
(https://www.cdc.gov/nchs/ndi/index.htm)
25
.

Study Design and Study Population
This was a population-based study using cross-sectional data from serial nationally-
representative samples of adults ≥18 years of age who participated in NHIS from 2004-2018.
Adults were categorized as with liver disease if they answered “yes” to any of the following
questions: “Ever had any chronic liver condition?” (N=1,398) or “Told had a liver condition, past
12 months” (N=7,317) or “Ever told by a doctor you had cancer; what kind of cancer…liver?”
(N=282). Adults who answered “no” to these questions were categorized as without liver
disease. We did not include adults who answered “yes” to “Ever had Hepatitis” (N=13,485) as

4
we hypothesized that this question could include a significant number of acute hepatitis cases not
relevant to chronic liver disease. The group without liver disease was further divided into
subgroups of history of cancer, history of emphysema, or history of coronary artery disease
based on responding “yes” to “Ever told by a doctor you had cancer?”, “Ever had a history of
emphysema”, or “Ever had a history of coronary artery disease, respectively (Figure 1). We
excluded adults with liver cancer from the comparison subgroup of adults with history of cancer.
We chose coronary artery disease, emphysema, and cancer as comparator groups because they
are common chronic diseases with high-cost and common acute decompensating events which
garner attention from the lay population, policy makers, and clinicians alike and it would provide
context to our findings regarding the financial burden of liver disease. Based upon the wording
of the question, participants categorized in the history of cancer group may have had a history
rather than a current diagnosis of cancer. The groups within no liver disease are not mutually
exclusive.

5
Figure 1: Consort Diagram

Selection of the study population from the National Health Interview Survey participants from
2004 to 2018
*CAD: coronary artery disease

Demographic Variables
Self-reported age, sex, race, Hispanic ethnicity, marital status, geographic region, educational
level, employment status, access to paid sick leave, household income, insurance status, and
alcohol use were collected. Alcohol use was further characterized as abstinent (no lifetime
drinks), former (no drinks in the past year), and current (drank within the past year). We also

6
utilized information regarding self-reported medical conditions (coronary artery disease,
emphysema, hypertension, and diabetes).

Outcomes
Our outcome was healthcare affordability (inability to afford medical services: prescription
medications, mental healthcare, dental care, eyeglasses, specialist care, and follow up care) and
accessibility issues (delays in care or needing care but not obtaining care), using services and
definitions available in NHIS previously validated as measures of global healthcare
affordability
22,24,26-28
.

Healthcare Affordability
Specifically, healthcare affordability issues were defined as answering “yes” to questions asking
adults to report difficulty affording any of these different types of services in the previous 12
months: prescription medications, mental healthcare, dental care, eyeglasses, specialist care, and
follow up care.

Healthcare Accessibility
Healthcare accessibility was defined as answering “yes” to questions asking adults if any of their
medical care was delayed in the past 12 months or if they needed but could not afford any
medical care.

7

Financial Distress
Financial distress was defined as answering “yes” to any of the questions assessing healthcare
affordability (prescription medications, mental healthcare, dental care, eyeglasses, specialist care,
and follow up care) or healthcare accessibility (delays in medical care and needing but could not
afford medical care).

Mortality
We also assessed all-cause mortality. The NHIS Public-Use Linked Mortality file was used, with
mortality determined for NHIS adults via linkage to the U.S. National Death Index through 2019
using the NHIS Public-Use Linked Mortality file. Follow up time was measured from time of
NHIS interview until death. Adults without a death record were considered alive and censored at
last follow up (December 31
st
, 2019).

Statistical analysis
Database Preparation
All statistical analyses utilized the stratification, clustering, and sampling weights to account for
the complex survey design. Survey characteristics were estimated as weighted means and
percentages stratified by presence of liver disease.
Age-adjusted proportion of healthcare affordability issues

8
We calculated age-adjusted proportions of adults reporting issues with healthcare affordability
by survey year (calculated using the direct standardization based on the standard 2000 US
population) for adults with and without liver disease, history of cancer, coronary artery disease,
and emphysema.
Multivariable Logistic Regression
We created multivariable logistic regression models to assess differences by adjusted odds ratio
(aOR) in healthcare accessibility and affordability between adults with liver disease vs adults
without liver disease, adults with cancer history, adults with emphysema, and adults with
coronary artery disease. All models were adjusted for recognized potential confounders
determined a priori by literature review (age, sex, marital status, survey year, region, education,
working for pay, household income, and insurance status [insured vs. uninsured])
17
. We
performed multiple imputation to handle missing data for household income
29
for the entire
study period using datasets obtained from the NHIS website (http://www.cdc.gov/nchs/nhis.htm)
containing imputed values. All other variables in multivariable models had <4% missingness. As
race and ethnicity are social constructs without biological implications and our models were
adjusted for key social determinants of health (income, education level, employment status, and
insurance), race and ethnicity were not included in our models
30
. If insurance status was known
but type of insurance was not known, participants were classified as having other insurance.
Our models assessed four outcomes: 1) unable to afford one of 6 medical services (medications,
follow up care, specialist care, mental health care, or dental healthcare) 2) unable to afford
prescription medications 3) delays in medical care in the past 12 months and 4) needing but did
not get medical care in the previous 12 months.

9

To evaluate the impact of the Affordable Care Act and account for the 2008 Global Financial
Crisis, which likely had a negative economic impact on the study participants, we divided the
study period into three eras: 2004-2007, 2008-2010, and 2011-2018.
In a sensitivity analysis, we repeated the main analysis using an expanded definition of liver
disease to include adults who answered “yes” to “Ever had Hepatitis”. Given >4% missing data
in the group without liver disease for race, diabetes, hypertension, and alcohol use, we performed
two separate post-hoc analysis of the main analysis: 1) limited to participants who had available
data adjusting for key medical comorbidities (diabetes, hypertension, and alcohol use), 2) limited
to participants with available data adjusting for race.
Mortality Analysis
We estimated all-cause age-adjusted mortality rates stratified by presence vs absence of financial
stress. As time of survey was arbitrary relative to age at survey time, time from survey to
mortality event is less meaningful compared to age to mortality event. Thus, we utilized left-
truncated time-to-event methods for Kaplan-Meier and Cox proportional hazards regression
models which were used to construct mortality curves and estimate adjusted hazards ratios (aHR)
for financial distress respectively. The models were adjusted for recognized confounders
determined a priori by literature review (sex, region, education, household income, and
insurance status (private insurance, public insurance, other insurance, and uninsured)
17
.

10
We used NHIS weighting in all models and performed analyses using SAS statistical software
(version 9.4, SAS Institute Inc). All data are publicly available and were deemed exempt by the
University of Southern California Institutional Review Board.

11
Chapter Three: Results
Of the 1,006,782 adults included in the study, 8,977 had liver disease. Adults with (vs without)
liver disease vs were more often aged 50-65 (41.3% vs 24.7%), Alaskan Native/Native American
(1.3% vs 0.9%), unmarried (60.3% vs 44.9%), originating from the western US region (25.3% vs
22.1%), not working for pay (65.0% vs 39.4%), with public insurance (36.9% vs 16.7%), and
had less than a high school degree (19.5% vs 13.8%). Compared to other chronic conditions
(history of cancer, adults with emphysema, and adults with coronary artery disease), adults with
liver disease were more often aged 50-65 (41.3% vs 28.3%, 33.2%, and 27.6% respectively),
Alaskan Native/Native American (1.3% vs 0.5%, 0.7%, and 0.7% respectively), Hispanic
ethnicity (14.2% vs 4.4%, 4.6% and 7.2% respectively), and originated from the western US
region (25.3% vs 20.6%, 16.5%, and 16.4% respectively). Full baseline demographics are
summarized in Table 1.

Table 1: Baseline Characteristics*
Baseline Characteristics
Liver Disease
(N=8,977)
(%)
Without
Liver Disease
(N=1,006,782)
(%)
History of
Cancer
(N=38,570)
(%)

Emphysema
(N=7,937)
(%)

CAD^
(N=21,510)
(%)
Age in Years

18-39

16.89

39.24

6.47

3.24

2.27
40-49 17.15 18.29 8.64 7.36 5.29
50-64 41.33 24.74 28.32 33.22 27.60
≥65 24.63 17.74 56.57 56.18 64.84
Sex
Female

52.08

51.75

60.06

51.08

42.25
Male 47.92 48.25 39.94 48.92 57.75

12
Race
Caucasian

82.33

80.16

90.15

88.71

84.97
Black 9.77 12.06 6.46 7.21 10.36
Alaskan Native/Native American 1.33 0.90 0.46 0.68 0.67
Asian 4.04 5.23 1.63 1.33 2.51
Other 0.10 0.18 0.06 0.12 0.09
Missing 2.62 1.67 1.41 2.15 1.61
Hispanic Ethnicity 14.15 14.46 4.44 4.55 7.21
Unmarried 60.30 44.87 52.57 63.07 53.96
Region
Northeast

15.87

17.53

17.21

15.83

17.54
Midwest 21.03 21.83 23.72 26.63 24.76
South 35.43 35.36 35.59 37.79 38.15
West 25.26 22.08 20.57 16.54 16.39
Missing 2.74 3.58 3.14 3.57 3.42
Education
Less than High school

19.46

13.81

13.68

30.29

22.30
Graduated High school/GED 26.58 27.25 26.87 34.09 29.56
More than High school 53.47 56.87 59.00 34.93 47.53
Missing 0.52 2.16 4.70 0.72 0.65
Not Working for Pay 64.95 39.42 68.53 84.20 78.59
Missing 0.03 0.93 11.16 0.04 0.04
Insured 88.76 84.10 95.42 93.49 95.66
Missing 0.21 1.06 1.30 0.15 0.14
Among adults with insurance:
Government-Sponsored
Insurance

36.89

16.65

30.22

49.00

53.41
Private Health Insurance 47.22 64.72 63.01 41.51 39.97
Missing 16.65 20.94 1.30 9.54 7.05
Income
≤$34,999/year

49.72

26.43

36.67

59.94

46.32
$35,000-$74,999/year 24.38 27.07 27.20 22.32 25.70
≥$75,000/year 18.45 30.89 24.73 8.36 16.47
Missing 7.44 15.60 11.16 9.40 11.17
Diabetes 23.33 3.95 16.12 21.24 30.83
Missing 3.39 57.44 2.65 3.58 3.67
Hypertension 53.64 13.61 53.55 62.63 76.04
Missing 0.20 56.78 0.12 0.11 0.15
Alcohol Use
Abstinent

16.46

8.66

17.91

15.96

22.01
Former 29.49 6.34 22.31 36.06 29.82
Current 52.13 27.53 57.83 45.52 46.18
Missing 1.99 57.71 1.92 2.32 2.05
Missing values for no LD: race (n=16,582), region (n=36,056), education (n=21,714), working for pay (n=9,374),
insurance (n=10,656), among adults with insurance (n=210,824), income (n=157,041), diabetes (n=578,296),
hypertension (n=571,623), alcohol use (n=580,989)
Missing values for LD: race (n= 235), region (n=246), education (n=47), working for pay (N=3), insurance (n=19),
among adults with insurance (n=1,495), income (n=668), diabetes (n=304), hypertension (n=18), alcohol use
(n=179)
Missing values for cancer history: race (n=544), region (n=1,211), education (n=1,813), working for pay (n=4,304),

13
insurance (n=501), among adults with insurance (n=4,304), income (n=4,304), diabetes (n=1,022), hypertension
(n=47), alcohol use (n=739)
Missing values for emphysema: race (n=171), region (n=283), education (n=57), working for pay (n=3),insurance
(n=12), among adults with insurance (n=757), income (n=746), diabetes (n=284), hypertension (n=9), alcohol use
(n=184)
Missing values for coronary artery disease: race (n=347), region (n=736), education (n=139), working for pay (n=8),
insurance (n=31) , among adults with insurance (n=1516), income (n=2403), diabetes (n=790), hypertension
(n=33), alcohol use (n=441)
*All reported Ns are unweighted and all % are weighted; percentages do not sum to 100 given missing data
^CAD=coronary artery disease

Trends in healthcare affordability issues
Age-adjusted proportions of adults reporting inability to afford 1 of 6 medical services by year
are shown in Figure 2A. Issues with affording medical services were more common in adults
with liver disease [36.8% (95% CI: 36.7%-37.0%)] vs. without liver disease [18.3% (95% CI:
18.2%-18.5%)] throughout the study period. Issues affording medical services among adults with
liver disease [36.8% (95% CI: 36.7%-37.0%)] were more common compared to coronary artery
disease [31.8% (95% CI: 31.6%-31.9%)] and history of cancer [27.0% (95% CI: 26.8%-27.2%)],
but not emphysema [43.2% (95% CI: 43.0%-43.3%)] (Figure 3A).
Age-adjusted proportions of adults reporting inability to afford prescription medications by year
are shown in Figure 2B. Medication affordability issues were more common in adults with liver
disease [20.4% (95% CI: 20.3%-20.5%)] vs.without liver disease [8.2% (95% CI: 8.1%-8.3%)]
throughout the study period. Medication affordability issues among adults with liver disease
[20.4% (95% CI: 20.3%-20.5%)] were more common compared to history of cancer [15.0%
(95% CI: 14.9%-15.1%)] but not to coronary artery disease [20.5% (95% CI: 20.4%-20.6%)] or
emphysema [26.4% (95% CI: 26.2%-26.5%)] (Figure 3B).

14
Figure 2: Age-adjusted proportion of adults reporting healthcare affordability issues from
2004-2018 in adults with and without liver disease

Issues with affording medical services were more common in adults with liver disease [36.8%
(95% CI: 36.7%-37.0%)] compared to adults without liver disease [18.3% (95% CI:18.2%-
18.5%)] throughout the study period (A). Medication affordability issues were more common in
adults with liver disease [20.4% (95% CI: 20.3%-20.5%)] compared to adults without liver
disease [8.2% (95% CI:8.1%-8.3%)] throughout the study period (B).

A
B

15
Figure 3: Age-adjusted proportion of adults reporting healthcare affordability issues from
2004-2018 in adults with liver disease, coronary artery disease, emphysema, and history of
cancer

When compared to other chronic conditions, issues affording medical services were most
common among adults with emphysema [43.2% (95% CI: 43.0%-43.3%)], followed by liver
disease [36.8% (95% CI: 36.7%-37.0%)], coronary artery disease [31.8% (95% CI: 31.6%-
31.9%)], and history of cancer [27.0% (95% CI: 26.8%-27.2%)] (A). When compared to other
chronic conditions, medication affordability issues among adults with liver disease [20.4% (95%
A
B

16
CI: 20.3%-20.5%)] were more common compared to history of cancer [15.0% (95% CI: 14.9%-
15.1%)] but not to coronary artery disease [20.5% (95% CI: 20.4%-20.6%)] or emphysema
[26.4% (95% CI: 26.2%-26.5%)] (Figure 3B).

Healthcare affordability and accessibility by liver disease status
Healthcare affordability and accessibility issues in adults with liver disease vs other chronic
conditions are summarized in Table 2. In multivariable analysis, adults with (vs. without) liver
disease were more likely to report inability to afford 1 of 6 medical services (aOR 2.21, 95% CI:
2.09-2.35, p<0.0001), inability to afford medications (aOR 2.36, 95% CI: 2.20-2.54, p<0.0001),
delays in medical care (aOR 2.12, 95% CI: 1.99-2.27, p<0.0001), and needing but not receiving
medical care (aOR 2.19, 95% CI: 2.04-2.36, p<0.0001). Full multivariable models are shown in
Table S6.
Age-adjusted proportions of adults with liver disease reporting healthcare affordability and
accessibility issues generally declined after 2010. In multivariable analysis, the 2011-2018 (vs.
2008-2010) era was associated with lower odds of inability to afford 1 of 6 medical services
(aOR 0.88, 95% CI: 0.85-0.90, <0.0001), inability to afford medications (aOR 0.75, 95% CI:
0.73-0.78, p<0.001), delays in medical care (aOR 0.83, 95% CI: 0.81-0.85, <0.0001), and
needing but not receiving medical care (aOR 0.86, 95% CI: 0.84-0.89, p<0.0001) (Table S6).
In multivariable analysis, adults with liver disease vs. with history of cancer were more likely to
report inability to afford 1 of 6 medical services (aOR 1.96, 95% CI: 1.70-2.25, p<0.0001),
inability to afford medications (aOR 1.58, 95% CI: 1.31-1.92, p<0.0001), delays in medical care
(aOR 1.75, 95% CI: 1.48-2.06, p<0.0001), and needing but not receiving medical care (aOR
1.58, 95% CI: 1.31-1.92, p<0.0001). Full multivariable models are shown in Table S7.

17
In multivariable analysis, adults with liver disease vs. emphysema were more likely to report
inability to afford 1 of 6 medical services (aOR 1.10, 95% CI: 1.02-1.20, p=0.02) only. Adults
with liver disease vs emphysema had similar likelihood of reporting inability to afford
medications (aOR 1.01, 95% CI: 0.92-1.12, p=0.77), delays in medical care (aOR 1.06, 95% CI:
0.95-1.17, p=0.27), and needing but not receiving medical care (aOR 1.06, 95% CI: 0.95-1.19,
p=0.27). Full multivariable models are shown in Table S8.
In multivariable analysis, adults with liver disease vs. coronary artery disease were more likely to
report inability to afford 1 of 6 medical services (aOR 1.36, 95% CI: 1.26-1.47, p<0.0001),
inability to afford medications (aOR 1.17, 95% CI: 1.06-1.28, p=0.001), delays in medical care
(aOR 1.27, 95% CI: 1.16-1.40, p<0.0001), and needing but not receiving medical care (aOR
1.27, 95% CI: 1.14-1.41, p<0.0001). Full multivariable models are shown in Table S9.
In a sensitivity analysis using an expanded definition of liver disease to include adults who
answered “yes” to “Ever had Hepatitis”, our results were similar for liver disease vs. no liver
disease, vs. history of cancer, vs. emphysema, and vs. coronary artery disease (Table S11).

In a post-hoc analysis adjusting for race in the main models, our results were similar for liver
disease vs. no liver disease, vs. history of cancer, vs. emphysema, and vs. coronary artery disease
(Table S12).

In a post-hoc analysis adjusting for key medical comorbidities (diabetes, hypertension, and
alcohol use) in the main models, our results were similar for liver disease vs. no liver disease, vs.
history of cancer, vs. emphysema, and vs. coronary artery disease (Table S13-S16).

18

Table 2: Multivariable model of healthcare affordability and accessibility issues in adults
with liver disease vs no liver disease or other chronic diseases

*aOR: Odds Ratio adjusted for age, sex, marital status, United States Census Region, education level,
Survey Year, employment, insurance coverage, and annual income
^CAD: Coronary Artery Disease
Factors associated with healthcare affordability and accessibility issues among liver disease
Multivariable models examining factors associated with healthcare affordability and accessibility
issues in adults with liver disease are shown in Table 3. Age <65 (in age 40-49 vs. >65—
medical services: aOR 3.49, 95% CI: 2.75-4.42; medication: aOR 4.03, 95% CI: 3.12-5.36; delay
in care: aOR 2.39, 95% CI: 1.75-3.26; needed care: aOR 3.49, 95% CI: 2.57-4.76), female sex
(vs. male—medical services: aOR 1.56, 95% CI: 1.35-1.81; medication: aOR 1.46, 95% CI:
1.23-1.73; delay in care: aOR 1.24, 95% CI: 1.04-1.46; needed care: aOR 1.13, 95% CI: 0.94-
1.35), residence in the US Census Southern region (vs. Northeast—medical services: aOR 1.91,
95% CI: 1.46-2.25; medication: aOR 1.41, 95% CI: 1.10-1.82; delay in care: aOR 1.51, 95% CI:

Model Outcome Variable
Unable to afford 1 of 6
Medical Services
Unable to Afford
Medications
Medical Care
Delayed
Needed but did not
get medical care
aOR* p value aOR* p value aOR* p value aOR* p value
Liver
Disease vs
No Liver
Disease
2.21
(2.09-2.35) <0.0001
2.36
(2.20-2.54) <0.0001
2.12
(1.99-2.27) <0.0001
2.19
(2.04-2.36) <0.0001
Liver
Disease vs
History of
Cancer
1.96
(1.70-2.25) <0.0001
1.58
(1.31-1.92) <0.0001
1.75
(1.48-2.06) <0.0001
1.58
(1.31-1.92) <0.0001
Liver
Disease vs
Emphyse
ma
1.10
(1.02-1.20) 0.02
1.01
(0.92-1.12) 0.77
1.06
(0.95-1.17) 0.27
1.06
(0.95-1.19) 0.27
Liver
Disease vs
CAD^
1.36
(1.26-1.47) <0.0001
1.17
(1.06-1.28) 0.001
1.27
(1.16-1.40) <0.0001
1.27
(1.14-1.41) <0.0001

19
1.17-1.94; needed care: aOR 1.63, 95% CI: 1.23-2.16), lack of insurance (vs. privately insured—
medical services: aOR 3.90, 95% CI: 3.09-4.93; medication: aOR 3.43, 95% CI: 2.68-4.38; delay
in care: aOR 5.04, 95% CI: 3.93-6.47; needed care: aOR 5.51, 95% CI: 4.26-7.11), and lower
income (<$35,000 vs. ≥$75,000 per year—medical services: aOR 4.16, 95% CI: 3.15-5.48;
medication: aOR 2.89, 95% CI: 1.97-4.22; delay in care: aOR 4.12, 95% CI: 2.92-5.81; needed
care: aOR 6.56, 95% CI: 4.15-10.37) were associated with increased likelihood of reporting
issues accessing medical services, affording prescription medications, delays in medical care,
and needing but not getting medical care. Diabetes was associated with increased likelihood of of
medication affordability issues only (vs. without diabetes—aOR 1.30, 95% CI: 1.06-1.58).
Former and current alcohol use were both associated with increased likelihood of healthcare
affordability and accessibility issues [(former alcohol use vs. abstinent—medical services: aOR
1.69, 95% CI 1.36-2.09; medication: aOR 1.45 95% CI: 1.12-1.87; delay in care: aOR 1.30, 95%
CI 1.00-1.70) (current alcohol use vs. abstinent—medical services: aOR 1.61, 95% CI 1.32-1.98;
medication: aOR 1.39, 95% CI: 1.09-1.77; delay in care: aOR 1.30, 95% CI 1.00-1.68). Among
those that had insurance, public insurance was associated with increased likelihood of healthcare
affordability issues (public vs private—medical services: aOR 1.68, 95% CI 1.39-2.02;
medication: aOR 1.29 95% CI: 1.02-1.63) only.
Table 3: Multivariable model of risk factors associated with healthcare affordability and
accessibility amongst adults with liver disease

Model Outcome
Unable to afford 1 of 6
medical services
(N=5,684)
Unable to afford
medications
(N=5,682)
Medical care delayed
(N=5,693)
Needed but did not get
medical care
(N=5,696)
aOR*
(95% CI) p value
aOR*
(95% CI) p value
aOR*
(95% CI) p value
aOR*
(95% CI) p value
Age
18-39
2.84
(2.19-3.68) <0.0001
3.20
(2.45-4.49) <0.0001
1.89
(1.36-2.61) 0.0001
1.99
(1.38-2.74) 0.0002
40-49
3.49
(2.75-4.42) <0.0001
4.03
(3.12-5.36) <0.0001
2.39
(1.75-3.26) <0.0001
3.49
(2.57-4.76) <0.0001

20
50-64
2.91
(2.39-3.55) <0.0001
2.79
(2.25-3.64) <0.0001
2.40
(1.84-3.12) <0.0001
2.68
(2.01-3.45) <0.0001
≥65
(ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Female Sex
1.56
(1.35-1.81) <0.0001
1.46
(1.23-1.73) <0.0001
1.24
(1.04-1.46) 0.01
1.13
(0.94-1.35) 0.19
Unmarried
1.05
(0.89-1.23) 0.59
1.09
(0.90-1.32) 0.40
1.38
(1.14-1.66) 0.001
1.31
(1.06-1.62) 0.01
Region
Northeast (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Midwest
1.39
(1.11-1.76) 0.005
1.13
(0.86-1.49) 0.38
1.21
(0.91-1.61) 0.18
1.21
(0.89-1.64) 0.23
South
1.91
(1.46-2.25) <0.0001
1.41
(1.10-1.82) 0.007
1.51
(1.17-1.94) 0.001
1.63
(1.23-2.16) 0.0006
West
1.76
(1.40-2.20) <0.0001
1.20
(0.92-1.58) 0.18
1.56
(1.21-2.02) 0.0007
1.43
(1.07-1.91) 0.02
Education
Less than
Highschool
0.77
(0.64-0.93) 0.006
0.87
(0.70-1.08) 0.20
0.62
(0.50-0.78) <0.0001
0.66
(0.53-0.83) 0.0004
Graduated
Highschool/GED
0.88
(0.74-1.05) 0.17
1.00
(0.82-1.23) 0.99
0.75
(0.61-0.91) 0.004
0.80
(0.64-1.00) 0.046
More than
Highschool (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
2011-2018 vs
2004-2010
1.18
(1.03-1.36) 0.02
0.97
(0.82-1.14) 0.69
0.93
(0.79-1.10) 0.39
0.81
(0.68-0.97) 0.02
No paid work
1.10
(0.92-1.32) 0.31
1.28
(1.03-1.57) 0.02
0.97
(0.80-1.19) 0.80
1.16
(0.93-1.45) 0.19
Insurance
Private (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Public
1.68
(1.39-2.02) <0.0001
1.29
(1.02-1.63) 0.03
0.90
(0.71-1.14) 0.39
0.95
(0.74-1.23) 0.71
Other
1.35
(0.98-1.86) 0.07
1.08
(0.72-1.63) 0.70
0.82
(0.54-1.25) 0.36
0.86
(0.54-1.36) 0.52
Uninsured
3.90
(3.09-4.93) <0.0001
3.43
(2.68-4.38) <0.001
5.04
(3.93-6.47) <0.0001
5.51
(4.26-7.11) <0.0001
Income
≤$34,999/year
4.16
(3.15-5.48) <0.0001
2.89
(1.97-4.22) <0.0001
4.12
(2.92-5.81) <0.0001
6.56
(4.15-10.37) <0.0001
$35,000-
$74,999/year
2.66
(2.03-3.49) <0.0001
2.38
(1.67-3.38) <0.0001
2.82
(2.01-3.97) <0.0001
3.27
(2.05-5.20) <0.0001
≥$75,000/year
and up (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Hypertension
1.26
(1.08-1.46) 0.003
1.46
(1.22-1.75) <0.0001
1.29
(1.08-1.55) 0.006
1.38
(1.13-1.69) 0.001
Diabetes
1.15
(0.97-1.36) 0.11
1.30
(1.06-1.58) <0.0001
1.19
(0.97-1.46) 0.09
0.96
(0.77-1.19) 0.72
Alcohol use
Abstinent (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Former
1.69
(1.36-2.09) <0.0001
1.45
(1.12-1.87) 0.004
1.30 (1.00-
1.70) 0.049
1.19
(0.91-1.57) 0.21
Current
1.61
(1.32-1.98) <0.0001
1.39
(1.09-1.77) 0.009
1.30 (1.00-
1.68) 0.048
1.12
(0.85-1.46) 0.43
*aOR: adjusted Odds Ratio

21
Association of mortality with healthcare affordability and accessibility issues among liver
disease
Among adults with liver disease, all-cause age-adjusted mortality rates were higher in adults
reporting financial distress [15.4 (95% CI: 14.6-16.1) deaths per 1,000 population] vs without
financial distress [13.2 (95% CI: 12.4 -14.0) per 1,000 population] (p<0.001) (Figure S2). In
multivariable analysis, financial distress (vs. without) was associated with higher risk of all-
cause mortality [aHR 1.13 (95% CI: 1.01-1.27)] (Table 4). Among financial distress
components, only inability to afford medications [aHR 1.13 (95% CI: 0.97-1.68)] was associated
with increased risk of mortality, whereas inability to afford medical services [aHR 1.13 (95% CI:
0.97-1.32)], needing but not receiving medical care [aHR 0.92 (95% CI: 0.75-1.13)], and delays
in medical care [aHR 1.05 (0.87-1.28)] was associated with similar risk of mortality (Table 4).
Table 4: Cox regression hazards model of the effects of financial distress^ on mortality
among patients with liver disease

^financial distress was defined as answering “yes” to questions assessing healthcare affordability
(prescription medications, mental healthcare, dental care, eyeglasses, specialist care, and follow up care)
or healthcare accessibility (delays in medical care and needing but could not afford medical care);*aHR:
Hazards Ratio adjusted for sex, US census region, education level, insurance coverage, income, diabetes,
and alcohol use

Mortality
aHR* p value
Financial distress^ 1.13 (1.01-1.27) 0.03
Unable to afford 1 of 6 medical services 1.13 (0.97-1.32) 0.11
Unable to afford medications 1.42 (1.19-1.68) <0.0001
Needed but did not getting care 0.92 (0.75-1.13) 0.44
Delayed care 1.05 (0.87-1.28) 0.59

22
Chapter Four: Discussion
In this national cohort study, we show that adults with liver disease are more likely than adults
with cancer history and coronary artery disease, and equally likely as emphysema, to report
healthcare affordability and accessibility issues. We observed an overall improvement in the
affordability of medical services from 2011-2018, which coincides with the enactment of the
Affordable Care Act, national legislation that increased accessibility of medical services and
coverage of medication,
31
supporting the potential value in governmental policies that expand
healthcare insurance. The Affordable Care Act provided tax credits and cost-sharing subsidies to
reduce out of pocket spending for adults with income under the federal poverty limit and
promote the purchase of health insurance. This has led to increased healthcare access and
utilization, particularly in low-income groups
32-34
. Despite some improvement in healthcare
affordability issues after 2011, our study highlights that adults with liver disease continue to face
significant financial distress
7,16,18
. Future studies exploring effective interventions addressing
financial distress with liver disease are critically needed.
We found that adults with liver disease are more likely to report financial distress compared to
adults with coronary artery disease and cancer history- well described cohorts that experience
financial distress
19,22
highlighting an alarming public health issue. Surprisingly, adults with liver
disease are equally likely as adults with emphysema to report financial distress. Previous studies
have highlighted that adults with emphysema commonly report financial distress likely
secondary to the high out of pocket costs of inhalers
35,36
. However, like liver disease, studies
looking at the impact of financial distress and mortality are lacking and desperately needed. Our
findings underscore the magnitude of financial distress that adults with liver disease face and

23
should provide motivation for center level studies to provide more granular data surrounding the
impact of financial burden of liver disease and healthcare utilization.
We found that financial distress was independently associated with a 13% higher risk of all-
cause mortality after adjustment for confounders among adults with liver disease. Although the
association between financial distress and mortality (e.g. financial toxicity) is well established in
other chronic diseases, such as cancer history and cardiovascular disease, the association is not as
well-described for adults with liver disease
19,37
. More specifically, we showed that issues
affording prescription medications associated was associated with a 42% increased risk of
mortality. While causal inference is limited in this observational study, previous studies have
demonstrated improved liver-related mortality in government funded Medicaid expansion states
vs non-expansion states;
38
we hypothesize that comprehensive insurance for at risk populations
provides greater access to medical services and coverage of prescription medications, thus
mitigating the association of financial distress and mortality observed in our study. We also
hypothesize that other causal mechanisms are important from our observed results. For example,
alcohol use (former and current) was independently associated with 40-60% increased risk of
mortality. Harmful alcohol use may cause liver disease or exacerbate underlying liver disease
thereby precipitating financial distress and mortality; separately alcohol use has been previously
linked to psychological distress and income reductions which can exacerbate the financial
distress from liver disease
39
. Although the primary mechanism of financial toxicity in the United
States is thought to be secondary to high out of pocket costs for medical care, financial toxicity
in adults with chronic disease is also prevalent in countries with socialized healthcare systems;
for example, a study from France found that 51% of patients with a history of cancer reported
financial toxicity
23,40-42
. Indeed, social relationships, economic hardship from unemployment,

24
and harmful alcohol use as a maladaptive coping mechanism have been associated with
increased mortality among adults with cirrhosis or other chronic diseases globally and may be
linked to financial toxicity
43,44
. Our study adds evidence and provides quantification that
increased access to comprehensive health insurance coverage, in addition to social policies that
address the morbidity and disability from chronic disease, may be important interventions to
mitigate financial distress and improve survival outcomes for adults with liver diseases
throughout the world.
Our results identified key demographic subgroups associated with financial distress (female sex,
age <65, residence in the US Census Southern region, and annual income <$75,000) among liver
disease, which represent potential targets for future interventions. While causality cannot be
confirmed, our results do have significant plausibility and build upon previous studies. The
increased likelihood of financial distress among adults aged <65 and the uninsured highlights the
potential protective effect of insurance coverage against financial distress, as American adults
automatically gain access to government-funded Medicare insurance at the age of 65. However,
the increased likelihood of financial distress among adults with public insurance and liver
disease highlights the need to further expand coverage and minimize copayments to reduce
healthcare affordability and accessibility issues. Our results build on previous observational
studies describing women as an at-risk population, highlighting the potential importance of
financial interventions to address sex-based disparities
18
. Indeed, financial incentives in form of
conditional cash transfers or medical service vouchers targeted towards low-income women in
the general population for reproductive and maternal health have been shown to improve health
outcomes and bridge sex-based disparities
45
. Finally, the increased likelihood of financial
distress in adults with liver disease in the US Census Southern region may be secondary to the

25
low density of primary care providers
46
and gastroenterologists
47
in this region, leading to late-
stage presentation of liver disease and increased high-cost healthcare utilization (i.e.
hospitalizations for acute events vs. outpatient care for preventive care) leading to financial
distress. Potentially broadening coverage of services, minimizing copayments, and increasing
eligibility for government sponsored insurance may aid in decreasing financial distress in these
vulnerable subpopulations. Additionally, novel methods of disseminating care (e.g., telehealth)
has been shown to decrease economic losses related to travel and productivity loss for not only
patients but also for caregivers within the cancer population and could potentially be useful in
adults with liver disease
48
. Furthermore, we hypothesize that centralized digitized electronic
medical records could increase efficiency, decrease healthcare costs, and stream-line care
delivery, thus reducing the financial burden and delays in care incurred by the patient
49
. Our
results should provide the impetus for prospective studies to examine the causal mechanisms of
these associations to better inform targeted interventions.

Among adults with liver disease, diabetes was associated with healthcare affordability issues,
potentially reflecting high out of pocket costs garnered from medications to treat diabetes, as
previously shown in the general population
50-54
. Interventions to alleviate financial distress in
this population are of particular interest given the correlation of decreased medication adherence
with increased out of pocket costs and the resultant increased healthcare utilization
55,56
. Using
generic formulations when feasible could potentially reduce annual out of pocket costs by 82%
for patients with diabetes
57
. Adherence-contingent rebates, an effective intervention for
increasing medication adherence in other populations with chronic diseases
58
, may prove to be an
effective strategy for diabetes. Finally, multi-disciplinary integrative care models, allowing for

26
alignment and collaboration within the medical home, have been associated with a 40%
improvement in medication adherence for adults with diabetes alone and may be particularly
effective in adults with both liver disease and diabetes
59
. Interestingly, diabetes did not
significantly increase the likelihood of healthcare accessibility issues (delays in medical care:
aOR 1.19, p=0.09; needing but not obtaining medical care: aOR 0.96, p=0.72) suggesting that
adults carrying a diagnosis of liver disease and diabetes (e.g. with non-alcoholic fatty liver
disease) are potentially more likely to have established medical care to aid in accessing services,
or with less acuity of disease that allows more time for appropriate healthcare access. Indeed,
prior studies have highlighted that the majority of patients with non-alcoholic fatty liver disease
are asymptomatic and are diagnosed incidentally
60,61
. In contrast, both former and current alcohol
use were independently associated with healthcare affordability issues and delays in medical care
suggesting that this group may not be as established in the medical system, as supported by data
showing that patients with alcohol-associated liver disease often have late presentation of disease
and increased healthcare utilization
61,62
. Community-based alcohol use screening and
interventions may be of benefit to increase early identification of adults at risk and increase
uptake of preventive cost-saving care.

There were limitations to this study. First, the survey structure is self-report, so the prevalence of
liver disease and reports of financial distress are potentially underreported, and variables are at-
risk for misclassification (including liver cancer potentially representing metastatic cancer to the
liver) and response bias—nonetheless, NHIS has been administered nationally for over 50 years
with careful selection of questions from validated survey instruments, and we hypothesize that
we have captured adults with clinically-diagnosed liver disease, which may be more relevant to

27
real-world practice. Second, adult with liver disease and financial distress may have accrued
other diagnoses prior to dying or surviving which was not captured in the data available. Third,
the study was retrospective and cross-sectional, so causal inference is limited and residual
confounding is possible. Fourth, our results are based upon a US population and its
generalizability to other countries, specifically in socialized healthcare systems, would need to be
assessed. Fifth we could not assess different stages or chronicity of liver disease or other
comorbid conditions, and granular social determinants of health to determine if duration of
chronic disease impacts the likelihood of facing financial distress and mortality though we
hypothesize that adults with chronic liver disease are more likely to utilize healthcare services
compared to adults with acute liver injury. These will be important areas for future prospective
studies. Finally, there are varying levels of financial distress related to healthcare, ranging from
mild budgetary tradeoffs to crippling medical debt, the spectrum of which could not be fully
evaluated with our data sources. To address this limitation, we did use various subcategories of
healthcare unaffordability that have been validated as useful metrics by previous literature, but
given the importance and understudied area of financial burden among patients with liver
disease, we propose that additional questions in datasets regarding severity of financial distress
be implemented.

The strengths of our study include the use of a nationally representative cohort to better identify
potential risk factors associated with financial distress in liver disease. Data from 2004-2018,
given the landmark passage of the Affordable Care Act in 2010, allows assessment of trends and
improved understanding of the evolving landscape of financial distress in the US. Finally,
comparison groups of other chronic medical conditions provides context for our findings within

28
the entire scope of medicine, to prioritize higher-level policy changes and guide healthcare
expenditure.

In summary, our study shows that adults with liver disease face more financial distress compared
to adults without liver disease, and adults with cancer history or coronary artery disease in the
US. The prevalence of financial distress has decreased since the Affordable Care Act enactment
but persists at high levels and is associated with a 50% increased risk of mortality among adults
with liver disease. These findings should encourage medical professionals to screen for financial
distress in patients diagnosed with liver disease and provide impetus to policymakers to improve
healthcare accessibility and affordability targeted to adults with liver disease.

29
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36
Appendices
Appendix A: Supplementary Tables

Table S1: Univariable model of healthcare affordability and accessibility issues in those with liver
disease vs no liver disease

Model Outcome Variable
Unable to afford 1 of 6
medical services
Unable to afford
medications Medical care delayed
Needed but did not get
medical care
OR p value OR p value OR p value OR p value
Liver Disease vs No
Liver Disease 2.54 (2.42-2.68) <0.0001 2.76 (2.59-2.94) <0.0001 2.47 (2.32-2.62) <0.0001 2.67 (2.50-2.86) <0.0001
Age
18 to 39 2.05 (1.99-2.11)
<0.0001
2.20 (2.13-2.32)
<0.0001
2.69 (2.61-3.78) <0.0001 3.03 (2.92-3.15) <0.0001
40 to <50 2.19 (2.12-2.26) <0.0001 2.59 (2.48-2.71) <0.0001
2.94 (2.85-3.04) <0.0001 3.33 (3.20-3.46) <0.0001
50 to <65 2.15 (2.09-2.21) <0.0001 2.43 (2.32-2.53) <0.0001
2.96 (2.87-3.06) <0.0001 3.18 (3.06-3.30) <0.0001
>65 (ref)
(ref)
(ref) (ref)
(ref) (ref) (ref) (ref)
Female Sex 1.44 (1.41-1.46) <0.0001 1.53 (1.49-1.57) <0.0001 1.20 (1.18-1.22) <0.0001 1.18 (1.16-1.20) <0.0001
Unmarried 1.73 (1.70-1.76) <0.0001 1.72 (1.68-1.77) <0.0001 1.83 (1.80-1.87) <0.0001 2.01 (1.96-2.05) <0.0001
Region
Northeast (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Midwest 1.25 (1.21-1.30) <0.0001 1.35 (1.28-1.42) <0.0001 1.45 (1.40-1.51) <0.0001 1.35 (1.29-1.41) <0.0001
South 1.47 (1.42-1.52) <0.0001 1.52 (1.55-1.70) <0.0001 1.56 (1.51-1.61) <0.0001 1.71 (1.65-1.78) <0.0001
West 1.45 (1.40-1.51) <0.0001 1.23 (1.17-1.30) <0.0001 1.46 (1.41-1.51) <0.0001 1.43 (1.37-1.48) <0.0001
Education
Less than Highschool
1.74 (1.70-1.78) <0.0001 2.01 (1.93-2.09) <0.0001 1.35 (1.32-1.38) <0.0001 1.76 (1.71-1.80) <0.0001
Graduated
Highschool/
GED
1.30 (1.27-1.32) <0.0001 1.35 (1.30-1.40) <0.0001 1.12 (1.10-1.15) <0.0001 1.32 (1.29-1.35) <0.0001
More than Highschool
(ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Survey Year
2004-2007 0.78 (0.75-0.81) <0.0001

0.65 (0.59-0.71) <0.0001 0.78 (0.75-0.80) <0.0001 0.79 (0.76-0.82) <0.0001
2008-2010 (ref) (ref)
(ref)
(ref) (ref) (ref) (ref) (ref)
2011-2018 0.82(0.80-0.84) <0.0001
0.80 (0.74-0.87)
<0.0001 0.76 (0.74-0.78) <0.0001 0.77 (0.74-0.79) <0.0001
No Paid Work
1.25 (1.23-1.27)
<0.0001
1.36 (1.32-1.39)
<0.0001
1.10 (1.08-1.12)
<0.0001
1.26 (1.24-1.28)
<0.0001
Insured
Private

(ref) (ref)

(ref) (ref)

(ref) (ref)

(ref) (ref)
Public
2.40 (2.35-2.46)
<0.0001
2.38 (2.30-2.45)
<0.0001
1.45 (1.42-1.49)
<0.0001
2.08 (2.02-2.14)
<0.0001
Other Insured
1.98 (1.88-2.09)
<0.0001
1.63 (1.50-1.76)
<0.0001
1.47 (1.40-1.56)
<0.0001
2.00 (1.88-2.13)
<0.0001
Uninsured
5.90 (5.76-6.04)
<0.0001
6.41 (6.22-6.61)
<0.0001
6.24 (6.12-6.38)
<0.0001
8.98 (8.77-9.20)
<0.0001
Income
≤$34,999/year

5.35 (5.18-5.52)

<0.0001

1.91 (1.85-1.98)

<0.0001

4.75 (4.60-4.89)

<0.0001

7.60 (7.31-7.90)

<0.0001
$35,000-$74,999/year 2.71 (2.62-2.80) <0.0001 1.37 (1.33-1.42) <0.0001 2.74 (2.65-2.83) <0.0001 3.54 (3.40-3.69) <0.0001
≥$75,000/year (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)

37

Table S2: Univariable model of healthcare affordability and accessibility issues in adults with liver
disease vs history of cancer

Model Outcome Variable
Unable to afford 1 of 6
medical services
Unable to afford
medications Medical care delayed
Needed but did not get
medical care
OR p value OR p value OR p value OR p value
Liver Disease vs
History of Cancer 2.60 (2.31-2.93) <0.0001 3.06 (2.63-3.55) <0.0001 2.24 (1.95-2.57) <0.0001 2.18 (1.86-2.55) <0.0001
Age
18 to 39 2.05 (1.99-2.11)

<0.0001 2.20 (2.13-2.32)

<0.0001 2.69 (2.61-3.78) <0.0001 3.03 (2.92-3.15) <0.0001
39 to 49 2.19 (2.12-2.26) <0.0001 2.59 (2.48-2.71) <0.0001
2.94 (2.85-3.04) <0.0001 3.33 (3.20-3.46) <0.0001
50 to 64 2.15 (2.09-2.21) <0.0001 2.43 (2.32-2.53) <0.0001
2.96 (2.87-3.06) <0.0001 3.18 (3.06-3.30) <0.0001
>65 (ref)
(ref)
(ref) (ref)
(ref) (ref) (ref) (ref)
Female Sex 1.44 (1.41-1.46) <0.0001 1.53 (1.49-1.57) <0.0001 1.20 (1.18-1.22) <0.0001 1.18 (1.16-1.20) <0.0001
Unmarried 1.73 (1.70-1.76) <0.0001 1.72 (1.68-1.77) <0.0001 1.83 (1.80-1.87) <0.0001 2.01 (1.96-2.05) <0.0001
Region
Northeast (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Midwest 1.25 (1.21-1.30) <0.0001 1.35 (1.28-1.42) <0.0001 1.45 (1.40-1.51) <0.0001 1.35 (1.29-1.41) <0.0001
South 1.47 (1.42-1.52) <0.0001 1.52 (1.55-1.70) <0.0001 1.56 (1.51-1.61) <0.0001 1.71 (1.65-1.78) <0.0001
West 1.45 (1.40-1.51) <0.0001 1.23 (1.17-1.30) <0.0001 1.46 (1.41-1.51) <0.0001 1.43 (1.37-1.48) <0.0001
Education
Less than Highschool
1.74 (1.70-1.78) <0.0001 2.01 (1.93-2.09) <0.0001 1.35 (1.32-1.38) <0.0001 1.76 (1.71-1.80) <0.0001
Graduated
Highschool/
GED
1.30 (1.27-1.32) <0.0001 1.35 (1.30-1.40) <0.0001 1.12 (1.10-1.15) <0.0001 1.32 (1.29-1.35) <0.0001
More than Highschool
(ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Survey Year
2004-2007 0.78 (0.75-0.81) <0.0001

0.65 (0.59-0.71) <0.0001 0.78 (0.75-0.80) <0.0001 0.79 (0.76-0.82) <0.0001
2008-2010 (ref) (ref)
(ref)
(ref) (ref) (ref) (ref) (ref)
2011-2018 0.82(0.80-0.84) <0.0001
0.80 (0.74-0.87)
<0.0001 0.76 (0.74-0.78) <0.0001 0.77 (0.74-0.79) <0.0001
No Paid Work
1.25 (1.23-1.27)
<0.0001
1.36 (1.32-1.39)
<0.0001
1.10 (1.08-1.12)
<0.0001
1.26 (1.24-1.28)
<0.0001
Uninsured
Private

(ref) (ref)

(ref) (ref)

(ref) (ref)

(ref) (ref)
Public
2.40 (2.35-2.46)
<0.0001
2.38 (2.30-2.45)
<0.0001
1.45 (1.42-1.49)
<0.0001
2.08 (2.02-2.14)
<0.0001
Other Insurance
1.98 (1.88-2.09)
<0.0001
1.63 (1.50-1.76)
<0.0001
1.47 (1.40-1.56)
<0.0001
2.00 (1.88-2.13)
<0.0001
Uninsured
5.90 (5.76-6.04)
<0.0001
6.41 (6.22-6.61)
<0.0001
6.24 (6.12-6.38)
<0.0001
8.98 (8.77-9.20)
<0.0001
Income
≤$34,999/year

5.35 (5.18-5.52)

<0.0001

1.91 (1.85-1.98)

<0.0001

4.75 (4.60-4.89)

<0.0001

7.60 (7.31-7.90)

<0.0001
$35,000-$74,999/year 2.71 (2.62-2.80) <0.0001 1.37 (1.33-1.42) <0.0001 2.74 (2.65-2.83) <0.0001 3.54 (3.40-3.69) <0.0001
≥$75,000/year (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)

38

Table S3: Univariable model of healthcare affordability in adults with liver disease vs emphysema

Model Outcome Variable
Unable to afford 1 of 6
medical services
Unable to afford
medications Medical care delayed
Needed but did not get
medical care
OR p value OR p value OR p value OR p value
Liver Disease vs
Emphysema 1.38 (1.29-1.48) <0.0001 1.27 (1.16-1.38) <0.0001 1.40 (1.29-1.53) <0.0001 1.36 (1.24-1.49) <0.0001
Age
18 to 39 2.05 (1.99-2.11)

<0.0001 2.20 (2.13-2.32)

<0.0001 2.69 (2.61-3.78) <0.0001 3.03 (2.92-3.15) <0.0001
39 to 49 2.19 (2.12-2.26) <0.0001 2.59 (2.48-2.71) <0.0001
2.94 (2.85-3.04) <0.0001 3.33 (3.20-3.46) <0.0001
50 to 64 2.15 (2.09-2.21) <0.0001 2.43 (2.32-2.53) <0.0001
2.96 (2.87-3.06) <0.0001 3.18 (3.06-3.30) <0.0001
>65 (ref)
(ref)
(ref) (ref)
(ref) (ref) (ref) (ref)
Female Sex 1.44 (1.41-1.46) <0.0001 1.53 (1.49-1.57) <0.0001 1.20 (1.18-1.22) <0.0001 1.18 (1.16-1.20) <0.0001
Unmarried 1.73 (1.70-1.76) <0.0001 1.72 (1.68-1.77) <0.0001 1.83 (1.80-1.87) <0.0001 2.01 (1.96-2.05) <0.0001
Region
Northeast (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Midwest 1.25 (1.21-1.30) <0.0001 1.35 (1.28-1.42) <0.0001 1.45 (1.40-1.51) <0.0001 1.35 (1.29-1.41) <0.0001
South 1.47 (1.42-1.52) <0.0001 1.52 (1.55-1.70) <0.0001 1.56 (1.51-1.61) <0.0001 1.71 (1.65-1.78) <0.0001
West 1.45 (1.40-1.51) <0.0001 1.23 (1.17-1.30) <0.0001 1.46 (1.41-1.51) <0.0001 1.43 (1.37-1.48) <0.0001
Education
Less than Highschool
1.74 (1.70-1.78) <0.0001 2.01 (1.93-2.09) <0.0001 1.35 (1.32-1.38) <0.0001 1.76 (1.71-1.80) <0.0001
Graduated
Highschool/
GED
1.30 (1.27-1.32) <0.0001 1.35 (1.30-1.40) <0.0001 1.12 (1.10-1.15) <0.0001 1.32 (1.29-1.35) <0.0001
More than Highschool
(ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Survey Year
2004-2007 0.78 (0.75-0.81) <0.0001

0.65 (0.59-0.71) <0.0001 0.78 (0.75-0.80) <0.0001 0.79 (0.76-0.82) <0.0001
2008-2010 (ref) (ref)
(ref)
(ref) (ref) (ref) (ref) (ref)
2011-2018 0.82(0.80-0.84) <0.0001
0.80 (0.74-0.87)
<0.0001 0.76 (0.74-0.78) <0.0001 0.77 (0.74-0.79) <0.0001
No Paid Work
1.25 (1.23-1.27)
<0.0001
1.36 (1.32-1.39)
<0.0001
1.10 (1.08-1.12)
<0.0001
1.26 (1.24-1.28)
<0.0001
Uninsured
Private (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Public
2.40 (2.35-2.46)
<0.0001
2.38 (2.30-2.45)
<0.0001
1.45 (1.42-1.49)
<0.0001
2.08 (2.02-2.14)
<0.0001
Other Insurance
1.98 (1.88-2.09)
<0.0001
1.63 (1.50-1.76)
<0.0001
1.47 (1.40-1.56)
<0.0001
2.00 (1.88-2.13)
<0.0001
Uninsured
5.90 (5.76-6.04)
<0.0001
6.41 (6.22-6.61)
<0.0001
6.24 (6.12-6.38)
<0.0001
8.98 (8.77-9.20)
<0.0001
Income
≤$34,999/year

5.35 (5.18-5.52)

<0.0001

1.91 (1.85-1.98)

<0.0001

4.75 (4.60-4.89)

<0.0001

7.60 (7.31-7.90)

<0.0001
$35,000-$74,999/year 2.71 (2.62-2.80) <0.0001 1.37 (1.33-1.42) <0.0001 2.74 (2.65-2.83) <0.0001 3.54 (3.40-3.69) <0.0001
≥$75,000/year (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)

39

Table S4: Univariable model of healthcare affordability in adults with liver disease vs coronary
artery disease

Model Outcome Variable
Unable to afford 1 of 6
medical services
Unable to afford
medications Medical care delayed
Needed but did not get
medical care
OR p value OR p value OR p value OR p value
Liver Disease vs
CAD* 2.28 (2.15-2.42) <0.0001 2.04 (1.89-2.20) <0.0001 2.20 (2.04-2.38) <0.0001 2.26 (2.08-2.45) <0.0001
Age
18 to 39 2.05 (1.99-2.11)

<0.0001 2.20 (2.13-2.32)

<0.0001 2.69 (2.61-3.78) <0.0001 3.03 (2.92-3.15) <0.0001
39 to 49 2.19 (2.12-2.26) <0.0001 2.59 (2.48-2.71) <0.0001
2.94 (2.85-3.04) <0.0001 3.33 (3.20-3.46) <0.0001
50 to 64 2.15 (2.09-2.21) <0.0001 2.43 (2.32-2.53) <0.0001
2.96 (2.87-3.06) <0.0001 3.18 (3.06-3.30) <0.0001
>65 (ref)
(ref)
(ref) (ref)
(ref) (ref) (ref) (ref)
Female Sex 1.44 (1.41-1.46) <0.0001 1.53 (1.49-1.57) <0.0001 1.20 (1.18-1.22) <0.0001 1.18 (1.16-1.20) <0.0001
Unmarried 1.73 (1.70-1.76) <0.0001 1.72 (1.68-1.77) <0.0001 1.83 (1.80-1.87) <0.0001 2.01 (1.96-2.05) <0.0001
Region
Northeast (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Midwest 1.25 (1.21-1.30) <0.0001 1.35 (1.28-1.42) <0.0001 1.45 (1.40-1.51) <0.0001 1.35 (1.29-1.41) <0.0001
South 1.47 (1.42-1.52) <0.0001 1.52 (1.55-1.70) <0.0001 1.56 (1.51-1.61) <0.0001 1.71 (1.65-1.78) <0.0001
West 1.45 (1.40-1.51) <0.0001 1.23 (1.17-1.30) <0.0001 1.46 (1.41-1.51) <0.0001 1.43 (1.37-1.48) <0.0001
Education
Less than Highschool
1.74 (1.70-1.78) <0.0001 2.01 (1.93-2.09) <0.0001 1.35 (1.32-1.38) <0.0001 1.76 (1.71-1.80) <0.0001
Graduated
Highschool/
GED
1.30 (1.27-1.32) <0.0001 1.35 (1.30-1.40) <0.0001 1.12 (1.10-1.15) <0.0001 1.32 (1.29-1.35) <0.0001
More than Highschool
(ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Survey Year
2004-2007 0.78 (0.75-0.81) <0.0001

0.65 (0.59-0.71) <0.0001 0.78 (0.75-0.80) <0.0001 0.79 (0.76-0.82) <0.0001
2008-2010 (ref) (ref)
(ref)
(ref) (ref) (ref) (ref) (ref)
2011-2018 0.82(0.80-0.84) <0.0001
0.80 (0.74-0.87)
<0.0001 0.76 (0.74-0.78) <0.0001 0.77 (0.74-0.79) <0.0001
No Paid Work
1.25 (1.23-1.27)
<0.0001
1.36 (1.32-1.39)
<0.0001
1.10 (1.08-1.12)
<0.0001
1.26 (1.24-1.28)
<0.0001
Insurance
Private (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Public
2.40 (2.35-2.46)
<0.0001
2.38 (2.30-2.45)
<0.0001
1.45 (1.42-1.49)
<0.0001
2.08 (2.02-2.14)
<0.0001
Other Insurance
1.98 (1.88-2.09)
<0.0001
1.63 (1.50-1.76)
<0.0001
1.47 (1.40-1.56)
<0.0001
2.00 (1.88-2.13)
<0.0001
Uninsured
5.90 (5.76-6.04)
<0.0001
6.41 (6.22-6.61)
<0.0001
6.24 (6.12-6.38)
<0.0001
8.98 (8.77-9.20)
<0.0001
Income
≤$34,999/year

5.35 (5.18-5.52)

<0.0001

1.91 (1.85-1.98)

<0.0001

4.75 (4.60-4.89)

<0.0001

7.60 (7.31-7.90)

<0.0001
$35,000-$74,999/year 2.71 (2.62-2.80) <0.0001 1.37 (1.33-1.42) <0.0001 2.74 (2.65-2.83) <0.0001 3.54 (3.40-3.69) <0.0001
≥$75,000/year (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
*CAD: coronary artery disease

40

Table S5: Univariable model of healthcare affordability in adults with liver disease by service type

Model Outcome Variable
Unable to afford
follow up^
Unable to afford
specialist^
Unable to afford
eyeglasses
Unable to afford dental
services
Unable to afford mental
health services
OR p value OR p value OR p value OR p value OR p value
Liver
Disease vs
No Liver
Disease
2.63
(2.37-2.92)
<0.0001
2.71
(2.46-2.99)
<0.0001
2.62
(2.45-2.80)
<0.0001
2.26
(2.14-2.40)
<0.0001
2.77
(2.50-3.06)
<0.0001
Age
18 to 39

3.30
(3.01-3.61)

<0.0001

2.61
(2.41-2.83)

<0.0001

5.30
(4.59-6.12)

<0.0001

2.29
(2.22-2.37)

<0.0001

6.42
(5.72-.721)

<0.0001
39 to 49

4.08
(3.71-4.48)
<0.0001
3.38
(3.11-3.68)
<0.0001
5.30
(4.59-6.11)
<0.0001
2.42
(2.33-2.51)
<0.0001
6.52
(5.79-7.35)
<0.0001
50 to 64

3.97
(3.63-4.34)
<0.0001
3.46
(3.20-3.74)
<0.0001
2.21
(1.91-2.56)
<0.0001
2.45
(2.17-2.33)
<0.0001
5.04
(4.48-5.67)
<0.0001
>65 (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Female
Sex
1.52
(1.45-1.60)
<0.0001
1.47
(1.41-1.54)
<0.0001
1.31
(1.26-1.35)
<0.0001
1.35
(1.32-1.38)
<0.0001
1.66
(1.58-1.74)
<0.0001
Unmarrie
d
1.68
(1.60-1.77)
<0.0001
1.66
(1.58-1.73)
<0.0001
1.73
(1.68-1.78)
<0.0001
1.70
(1.67-1.74)
<0.0001
2.29
(2.18-2.41)
<0.0001
Region
Northeast

(ref)

(ref)

(ref)

(ref)

(ref)

(ref)

(ref)

(ref)

(ref)

(ref)
Midwest
1.30
(1.18-1.42)
<0.0001
1.18
(1.09-1.29)
0.0001
1.31
(1.24-1.38)
<0.0001
1.25
(1.20-1.30)
<0.0001
1.27
(1.17-1.38)
<0.0001
South
1.70
(1.56-1.85)
<0.0001
1.53
(1.42-1.66)
<0.0001
1.55
(1.48-1.63)
<0.0001
1.51
(1.45-1.57)
<0.0001
1.29
(1.19-1.39)
<0.0001
West
1.58
(1.44-1.73)
<0.0001
1.53
(1.41-1.67)
<0.0001
1.51
(1.43-1.59)
<0.0001
1.60
(1.53-1.66)
<0.0001
1.48
(1.37-1.60)
<0.0001
Education
Less than
Highscho
ol

1.84
(1.73-1.95)

<0.0001

1.75
(1.65-1.85)

<0.0001

1.89
(1.92-1.96)

<0.0001

1.63
(1.58-1.67)

<0.0001

1.22
(1.15-1.29)

<0.0001
Graduated
Highscho
ol/
GED
1.26
(1.19-1.33)
<0.0001
1.19
(1.12-1.25)
<0.0001
1.33
(1.29-1.37)
<0.0001
1.28
(1.25-1.31)
<0.0001
1.03
(0.79-1.08)
0.37
More than
Highscho
ol
(ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Survey
Year
2004

0.78
(0.71-0.86)
<0.0001
0.73
(0.64-0.74)
<0.0001
0.71
(0.62-0.82)
<0.0001
2005

0.75
(0.70-0.81)
<0.0001
0.72
(0.64-0.73)
<0.0001
0.88
(0.79-0.99)
0.03
2006

0.76
(0.70-0.82)
<0.0001
0.73
(0.64-0.75)
<0.0001
0.81
(0.71-0.92)
0.001
2007

0.75
(0.70-0.81)
<0.0001
0.73
(0.62-0.73)
<0.0001
0.89
(0.79-1.01)
0.06
2008

0.89
(0.83-0.96)
0.004
0.91
(0.80-0.94)
0.003
1.01
(0.89-1.14)
0.93
2009

0.94
(0.87-1.01)
0.09
0.96
(0.84-0.98)
0.2
1.01
(0.89-1.13)
0.93

41

^ Unable to afford follow up and Unable to afford specialist care data only available from 2011-2017

2010

(ref) (ref) (ref) (ref) (ref) (ref)
2011
1.54
(1.38-1.70)
<0.0001
1.34
(1.22-1.47)
<0.0001
0.93
(0.87-0.99)
0.02
0.94
(0.90-1.03)
0.02
1.00
(0.90-1.11)
0.93
2012
1.39
(1.26-1.54)
<0.0001
1.18
(1.08-1.30)
0.0003
0.86
(0.81-0.92)
<0.0001
0.83
(0.77-0.90)
<0.0001
0.88
(0.79-0.98)
0.98
2013
1.29
(1.16-1.45)
<0.0001
1.14
(1.04-1.25)
0.007
0.80
(0.75-0.86)
<0.0001
0.80
(0.79-0.91)
<0.0001
0.75
(0.66-0.84)
0.02
2014
1.11
(0.98-1.24)
0.09
1.01
(0.92-1.11)
0.84
0.71
(0.66-0.77)
<0.0001
0.72
(0.73-0.85)
<0.0001
0.68
(0.60-0.77)
<0.0001
2015
1.02
(0.91-1.15)
0.69
0.95
(0.86-1.05)
0.34
0.72
(0.67-0.78)
<0.0001
0.67
(0.66-0.80)
<0.0001
0.67
(0.59-0.75)
<0.0001
2016
0.90
(0.80-1.02)
0.09
0.91
(0.82-1.01)
0.08
0.62
(0.57-0.67)
<0.0001
0.63
(0.67-0.79)
<0.0001
0.67
(0.59-0.76)
<0.0001
2017
(ref) (ref) (ref) (ref)
0.65
(0.59-0.70)
<0.0001
0.66
(0.60-0.82)
<0.0001
0.74
(0.65-0.84)
<0.0001
2018

0.70
(0.65-0.76)
<0.0001
0.71
(0.71-0.83)
<0.0001
0.92
(0.82-1.04)
0.18
No Paid
Work
1.29
(1.23-1.35)
<0.0001
1.30
(1.25-1.36)
<0.0001
1.41 (1.37-
1.44)
<0.0001
1.22 (1.20-
1.25)
<0.0001
1.35
(1.29-1.41)
<0.0001
Insurance
Private

(ref)

(ref)

(ref)

(ref)

(ref)

(ref)

(ref)

(ref)

(ref)

(ref)
Public
2.04
(1.90-2.20)
<0.0001
2.17
(2.04-2.30)
<0.0001
2.70 (2.61-
2.80)
<0.0001
2.44 (2.37-
2.50)
<0.0001
2.13
(2.01-2.26)
<0.0001
Other
Insurance
1.83
(1.57-2.12)
<0.0001
1.78
(1.56-2.02)
<0.0001
1.99 (1.84-
2.14)
<0.0001
2.31 (2.18-
2.45)
<0.0001
2.08
(1.83-2.36)
<0.0001
Uninsured
8.68
(8.18-9.22)
<0.0001
6.78
(6.41-7.17)
<0.0001
5.41 (5.24-
5.60)
<0.0001
6.46 (6.29-
6.64)
<0.0001
5.80
(5.50-6.10)
<0.0001
Income
≤$34,999/
year

5.84
(5.33-6.41)

<0.0001

5.06
(4.68-5.48)

<0.0001

6.51 (6.19-
6.85)

<0.0001

5.42 (5.22-
5.63)

<0.0001

5.00
(4.62-5.41)

<0.0001
$35,000-
$74,999/y
ear
2.86
(2.60-3.16)
<0.0001
2.53
(2.33-2.76)
<0.0001
2.99 (2.93-
3.16)
<0.0001
2.79 (2.68-
2.91)
<0.0001
2.46
(2.25-2.68)
<0.0001
≥$75,000/
year
(ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)

42
Table S6: Multivariable model of healthcare affordability and accessibility issues in adults with
liver disease vs without liver disease

Model Outcome Variable
Unable to afford 1 of 6
medical services
N=397,367
Unable to afford
medications
N=397,269
Medical care delayed
N=894,148
Needed but did not get
medical care
N=894,120
aOR* p value aOR* p value aOR* p value aOR* p value
Liver Disease vs
Without Liver Disease 2.21 (2.09-2.35) <0.0001 2.36 (2.20-2.54) <0.0001 2.12 (1.99-2.27) <0.0001 2.19 (2.04-2.36) <0.0001
Age
18-39 2.21 (2.14-2.29) <0.0001 2.23 (2.12-2.34) <0.0001 1.97 (1.90-2.04) <0.0001 2.23 (2.14-2.33) <0.0001
40-49
3.03 (2.92-3.14) <0.0001 3.25 (3.09-3.43) <0.0001 2.94 (2.82-3.06) <0.0001 3.45 (3.30-3.62) <0.0001
50-64
2.88 (2.79-2.99) <0.0001 3.00 (2.86-3.15) <0.0001 3.19 (3.08-3.31) <0.0001 3.57 (3.42-3.73) <0.0001
≥65
(ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Female Sex
1.50 (1.47-1.54) <0.0001 1.59 (1.54-1.64) <0.0001 1.26 (1.24-1.28) <0.0001 1.25 (1.23-1.27) <0.0001
Unmarried
1.10 (1.07-1.12) <0.0001 1.09 (1.05-1.12) <0.0001 1.33 (1.28-1.38) <0.0001 1.33 (1.29-1.36) <0.0001
Region
Northeast (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Midwest
1.21 (1.16-1.25) <0.0001 1.27 (1.21-1.34) <0.0001 1.33 (1.28-1.38) <0.0001 1.21 (1.16-1.26) <0.0001
South
1.25 (1.20-1.29) <0.0001 1.32 (1.26-1.39) <0.0001 1.22 (1.18-1.26) <0.0001 1.27 (1.23-1.32) <0.0001
West
1.35 (1.30-1.41) <0.0001 1.10 (1.04-1.16) 0.0004 1.26 (1.21-1.30) <0.0001 1.18 (1.14-1.24) <0.0001
Education
Less than Highschool 0.93 (0.90-0.96) <0.0001 0.98 (0.94-1.02) 0.36 0.65 (0.63-0.65) <0.0001 0.73 (0.71-0.76) <0.0001
Graduated
Highschool/
GED 0.92 (0.90-0.94) <0.0001 0.94 (0.91-0.97) 0.0005 0.75 (0.73-0.76) <0.0001 0.81 (0.79-0.84) <0.0001
More than Highschool
(ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Survey Year
2004-2007 0.75 (0.73-0.78) <0.0001 0.83 (0.79-0.86) <0.0001 0.77 (0.74-0.80) <0.0001 0.79 (0.76-0.82) <0.0001
2008-2010 (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
2011-2018 0.88 (0.85-0.90) <0.0001 0.75 (0.73-0.78) <0.0001 0.83 (0.81-0.85) <0.0001 0.86 (0.84-0.89) <0.0001
No Paid Work 1.12 (1.10-1.15) <0.0001 1.25 (1.21-1.29) <0.0001 1.11 (1.08-1.13) <0.0001 1.16 (1.14-1.19) <0.0001
Insurance Status
Private (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Public 1.93 (1.87-1.99) <0.0001 1.73 (1.66-1.80) <0.0001 1.18 (1.15-1.22) <0.0001 1.47 (1.42-1.52) <0.0001
Other Insured 1.41 (1.33-1.49) <0.0001 1.09 (1.00-1.18) 0.06 1.02 (0.96-1.08) 0.52 1.26 (1.18-1.35) <0.0001
Uninsured 3.85 (3.74-3.96) <0.0001 3.97 (3.83-4.32) <0.0001 4.50 (4.38-4.62) <0.0001 5.65 (5.48-5.82) <0.0001
Income
≤$34,999/year 3.50 (3.37-3.63) <0.0001
3.85 (3.63-4.08)
<0.0001 3.37 (3.25-3.49) <0.0001 4.47 (4.27-4.68) <0.0001
$35,000-$74,999/year
2.27 (2.19-2.35) <0.0001 2.45 (2.32-2.59) <0.0001 2.26 (2.19-2.34) <0.0001 2.66 (2.54-2.78) <0.0001
≥$75,000/year (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)

*aOR: adjusted Odds Ratio

43
Table S7: Multivariable model of healthcare affordability and accessibility issues in adults with
liver disease vs history of cancer

*aOR: adjusted Odds Ratio

Model Outcome Variable
Unable to afford 1 of 6
Medical Services
N=36,640
Unable to Afford
Medications
N=36,365
Medical Care Delayed
N=37,026
Needed but did not get
medical care
N=37,022
aOR* p value aOR* p value aOR* p value aOR* p value
Liver Disease
vs History of
Cancer 1.96 (1.70-2.25) <0.0001 1.58 (1.31-1.92) <0.0001 1.75 (1.48-2.06) <0.0001 1.58 (1.31-1.92) <0.0001
Age
18 to 39 4.49 (3.93-5.11) <0.0001 4.35 (3.63-5.23) <0.0001 3.45 (2.95-4.07) <0.0001 4.35 (3.63-5.23) <0.0001
39 to 49 5.00 (4.42-5.66) <0.0001 5.96 (5.05-7.04) <0.0001 5.19 (4.47-6.03) <0.0001 5.96 (5.05-7.04) <0.0001
50 to 64 3.53 (3.24-3.84) <0.0001 4.29 (3.78-4.88) <0.0001 4.15 (3.72-4.62) <0.0001 4.29 (3.78-4.88) <0.0001
>65 (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Female Sex 1.49 (1.38-1.60) <0.0001 1.25 (1.12-1.39) <0.0001 1.25 (1.14-1.37) <0.0001 1.25 (1.12-1.39) 0.0001
Unmarried 1.10 (1.02-1.19) 0.01 1.47 (1.32-1.65) 0.003 1.55 (1.40-1.70) <0.0001 1.47 (1.32-1.65) <0.0001
Region
Northeast (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Midwest 1.20 (1.07-1.34) 0.001 1.18 (1.00-1.40) 0.048 1.28 (1.11-1.48) 0.0006 1.18 (1.00-1.40) 0.048
South 1.27 (1.15-1.41) <0.0001 1.26 (1.08-1.47) 0.004 1.39 (1.22-1.59) <0.0001 1.26 (1.08-1.47) 0.004
West 1.48 (1.32-1.65) <0.0001 1.35 (1.13-1.61) 0.0007 1.65 (1.42-1.90) <0.0001 1.35 (1.13-1.61) 0.0007
Education
Less than
Highschool 1.11 (1.00-1.23) 0.047 0.90 (0.78-1.04) 0.17 0.84 (0.74-0.95)

0.007
0.90 (0.78-1.04)

0.17
Graduated
Highschool/
GED 0.91 (0.84-0.99) 0.03 0.83 (0.74-0.93) 0.002 0.77 (0.69-0.85)

<0.0001
0.83 (0.74-0.93)

0.002
More than
Highschool (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Survey Year
2004-2007 0.80 (0.71-0.90) 0.0001 0.88 (0.75-1.03) 0.11 0.87 (0.76-1.00) 0.04 0.88 (0.75-1.03) 0.11
2008-2010 (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
2011-2018 1.04 (0.95-1.13) 0.39 0.88 (0.77-0.99) 0.03 0.89 (0.80-0.98) 0.02 0.88 (0.78-0.99) 0.03
No Paid
Work 1.08 (0.99-1.18) 0.08 1.27 (1.14-1.43) <0.0001 0.87 (0.78-0.96) 0.008 0.98 (0.87-1.11) 0.77
Insurance
Private (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Public 1.73 (1.60-1.87) <0.0001 1.49 (1.31-1.69) <0.0001 1.21 (1.09-1.35) 0.0003 1.49 (1.31-1.69) <0.0001
Other 1.43 (1.17-1.74) 0.0004 1.05 (0.77-1.41) 0.77 0.94 (0.74-1.21) 0.65 1.05 (0.77-1.41) 0.78
Uninsured 5.13 (4.48-5.88) <0.0001 8.15 (6.99-9.51) <0.0001 6.60 (5.73-7.60) <0.0001 8.15 (6.99-9.51) <0.0001
Income
≤$34,999/yea
r 5.05 (4.47-5.71) <0.0001 6.59 (5.33-8.14) <0.0001 4.63 (3.95-5.42)

<0.0001
6.59 (5.33-8.14)

<0.0001
$35,000-
$74,999/year 2.37 (2.09-2.68) <0.0001 2.90 (2.35-3.59) <0.0001 2.44 (2.10-2.83)
<0.0001
2.90 (2.35-3.59)
<0.0001
≥$75,000/yea
r (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)

44
Table S8: Multivariable model of healthcare affordability and accessibility issues in adults with
liver disease vs emphysema

*aOR: adjusted Odds Ratio

Model Outcome Variable
Unable to afford 1 of 6
Medical Services
N=15,438
Unable to Afford
Medications
N=15,434
Medical Care Delayed
N=15,547
Needed but did not get
medical care
N=15,550
aOR* p value aOR* p value aOR* p value aOR* p value
Liver Disease
vs Emphysema 1.10 (1.02-1.20) 0.02 1.01 (0.92-1.12) 0.77 1.06 (0.95-1.17) 0.27 1.06 (0.95-1.19) 0.27
Age
18 to 39 2.79 (2.39-3.26) <0.0001 2.73 (2.28-3.28) <0.0001 2.00 (1.64-2.43) <0.0001 2.23 (1.81-2.73) <0.0001
39 to 49
3.52 (3.09-4.01) <0.0001 3.42 (2.93-4.01) <0.0001 3.01 (2.55-3.56) <0.0001 3.53 (2.96-4.22) <0.0001
50 to 64
2.89 (2.62-3.18) <0.0001 2.67 (2.35-3.02) <0.0001 2.90 (2.55-3.29) <0.0001 2.94 (2.56-3.37) <0.0001
>65
(ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Female Sex
1.51 (1.40-1.63) <0.0001 1.45 (1.32-1.60) <0.0001 1.28 (1.17-1.41)
0.01
1.15 (1.03-1.27)
0.01
Unmarried
1.03 (0.94-1.12) 0.55 1.06 (0.95-1.18) 0.32 1.26 (1.13-1.41)
0.0003
1.25 (1.10-1.40)
0.0003
Region
Northeast (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Midwest
1.20 (1.05-1.36) 0.006 1.10 (0.94-1.28) 0.22 1.38 (1.18-1.61)
0.004
1.30 (1.09-1.54)
0.004
South
1.35 (1.20-1.52) <0.0001 1.17 (1.01-1.35) 0.04 1.57 (1.36-1.81)
<0.0001
1.63 (1.35-1.90)
<0.0001
West
1.36 (1.19-1.55) <0.0001 0.98 (0.83-1.15) 0.80 1.45 (1.24-1.70)
0.0002
1.39 (1.17-1.65)
0.0002
Education
Less than
Highschool 0.90 (0.82-1.00) 0.06 0.94 (0.83-1.06) 0.28 0.72 (0.64-0.82)

0.004
0.82 (0.71-0.94)
0.004
Graduated
Highschool/
GED 0.86 (0.79-0.95) 0.003 0.87 (0.78-0.98) 0.02 0.79 (0.70-0.88)
0.01
0.86 (0.76-0.97)
0.01
More than
Highschool (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Survey Year
2004-2007 0.89 (0.78-1.01) 0.06 1.04 (0.90-1.21) 0.58 0.96 (0.83-1.10) 0.96 1.00 (0.86-1.16) 0.96
2008-2010 (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
2011-2018 1.14 (1.03-1.27) 0.009 0.98 (0.87-1.11) 0.73 0.88 (0.78-0.98) 0.002 0.82 (0.72-0.93) 0.002
No Paid Work 1.27 (1.15-1.41) <0.0001 1.25 (1.10-1.42) 0.0006 0.92 (0.81-1.03) 0.06 1.13 (0.99-1.30) 0.06
Insurance
Private (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Public 1.47 (1.33-1.62) <0.0001 1.22 (1.07-1.38) 0.002 0.92 (0.81-1.04) 0.75 0.98 (0.85-1.12) 0.75
Other 1.18 (0.97-1.44) 0.10 0.76 (0.59-1.00) 0.047 0.67 (0.52-0.88) 0.04 0.74 (0.55-0.98) 0.04
Uninsured 3.85 (3.33-4.46) <0.0001 3.88 (3.33-4.53) <0.0001 5.10 (4.39-5.92) <0.0001 5.53 (4.72-6.48) <0.0001
Income
≤$34,999/year 3.83 (3.25-4.50) <0.0001 3.00 (2.43-3.70) <0.0001 3.50 (2.85-4.30)

<0.0001 5.45 (4.19-7.10)

<0.0001
$35,000-
$74,999/year 2.15 (1.84-2.51) <0.0001 2.01 (1.64-2.46) <0.0001 2.37 (1.95-2.89)
<0.0001
3.18 (2.44-4.14)
<0.0001
≥$75,000/year (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)

45
Table S9: Multivariable model of healthcare affordability and accessibility issues in adults with
liver disease vs coronary artery disease

^CAD: Coronary Artery Disease; *aOR: adjusted Odds Ratio

Model Outcome Variable
Unable to afford 1 of 6
Medical Services
(N=27,712)
Unable to Afford
Medications
(N=27,706)
Medical Care Delayed
(N=27,957)
Needed but did not get
medical care
(N=27,961)
aOR* p value aOR* p value aOR* p value aOR* p value
Liver Disease
vs CAD^ 1.36 (1.26-1.47) <0.0001 1.17 (1.06-1.28) 0.001 1.27 (1.16-1.40) <0.0001 1.27 (1.14-1.41) <0.0001
Age
18 to 39 2.88 (2.49-3.34) <0.0001 3.23 (2.69-3.87) <0.0001 2.33 (1.92-2.82) <0.0001 2.67 (2.16-3.30) <0.0001
39 to 49
3.84 (3.40-4.33) <0.0001 4.31 (3.73-4.98) <0.0001 3.72 (3.19-4.34) <0.0001 4.47 (3.80-5.27) <0.0001
50 to 64
3.24 (2.99-3.52) <0.0001 3.31 (2.97-3.69) <0.0001 3.39 (3.05-3.77) <0.0001 3.51 (3.11-3.96) <0.0001
>65
(ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Female Sex
1.45 (1.35-1.55) <0.0001 1.40 (1.28-1.52) <0.0001 1.20 (1.10-1.31)
<0.0001
1.11 (1.01-1.22)
0.04
Unmarried
1.03 (0.95-1.11) 0.49 1.08 (0.98-1.19) 0.10 1.33 (1.21-1.47)
<0.0001
1.37 (1.13-1.59)
0.0006
Region
Northeast (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Midwest
1.25 (1.12-1.40) 0.0003 1.08 (1.04-1.36) 0.01 1.37 (1.18-1.58)
0.0008
1.34 (1.13-1.59)
0.0006
South
1.34 (1.20-1.48) <0.0001 1.19 (1.05-1.35) 0.008 1.45 (1.26-1.65)
<0.0001
1.59 (1.37-1.85)
<0.0001
West
1.44 (1.29-1.62) <0.0001 1.19 (0.93-1.24) 0.35 1.37 (1.18-1.59)
<0.0001
1.35 (1.14-1.60)
0.0006
Education
Less than
Highschool 0.91 (0.83-0.99) 0.03 0.95 (0.85-1.07) 0.40 0.78 (0.69-0.87)
0.0048
0.88 (0.78-0.99)
0.04
Graduated
Highschool/
GED 0.84 (0.78-0.91) <0.0001 0.87 (0.78-0.96) 0.008 0.77 (0.69-0.86)
<0.0001
0.86 (0.77-0.97)
0.01
More than
Highschool (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Survey Year
2004-2007 0.77 (0.69-0.86) <0.0001 0.90 (0.79-1.04) 0.15 0.86 (0.74-1.00) 0.04 1.02 (0.87-1.18) 0.83
2008-2010 (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
2011-2018 1.01 (0.93-1.11) 0.78 0.89 (0.80-1.00) 0.0498 0.88 (0.79-0.98) 0.02 0.90 (0.80-1.01) 0.07
No Paid Work 1.09 (0.99-1.19) 0.09 1.17 (1.04-1.31) 0.009 0.88 (0.78-0.98) 0.02 0.98 (0.87-1.10) 0.69
Uninsured
Private (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Public 1.56 (1.44-1.69) <0.0001 1.34 (1.20-1.49) <0.0001 1.14 (1.02-1.27) 0.02 1.33 (1.18-1.51) <0.0001
Other 1.21 (1.01-1.45) 0.03 0.86 (0.68-1.09) 0.22 0.77 (0.61-0.98) 0.03 0.98 (0.76-1.26) 0.86
Uninsured 4.02 (3.52-4.58) <0.0001 4.23 (3.67-4.87) <0.0001 5.79 (5.03-6.66) <0.0001 7.04 (6.07-8.17) <0.0001
Income
≤$34,999/year 4.49 (3.92-5.16) <0.0001 3.74 (3.11-4.50) <0.0001 3.65 (3.06-4.33)

<0.0001 4.78 (3.85-5.93)

<0.0001
$35,000-
$74,999/year 2.45 (2.14-2.81) <0.0001 2.38 (1.99-2.85) <0.0001 2.42 (2.03-2.89)
<0.0001
2.71 (2.17-3.39)
<0.0001
≥$75,000/year (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)

46

Table S10: Multivariable model of healthcare affordability by service type in adults with liver disease vs no liver
disease

Model Outcome Variable
Unable to afford
follow up
N=228,253
Unable to afford
specialist
N=228,250
Unable to afford
eyeglasses
N=419,904
Unable to afford
dental services
N=419,925
Unable to afford
mental health services
N=419,930
aOR* p value aOR* p value aOR* p value aOR* p value aOR* p value
Liver Disease
vs No Liver
Disease
2.23
(1.98-2.51) <0.0001
2.20
(1.97-2.45) <0.0001
1.95
(1.81-2.10) <0.0001
1.94
(1.82-2.07) <0.0001
2.32
(2.09-2.59) <0.0001
Age
18 to 39
2.85
(2.57-3.15) <0.0001
2.49
(2.28-2.73) <0.0001
1.76
(1.68-1.85) <0.0001
2.33
(2.24-2.43) <0.0001
7.14
(6.32-8.03) <0.0001
39 to 49

4.29
(3.85-4.77) <0.0001
3.94
(3.58-4.33) <0.0001
3.17
(3.01-3.35) <0.0001
3.08
(2.95-3.21) <0.0001
9.00
(7.93-10.2) <0.0001
50 to 64

4.22
(3.83-4.66) <0.0001
4.00
(3.67-4.35) <0.0001
3.51
(3.35-3.68) <0.0001
2.80
(2.69-2.91) <0.0001
6.49
(5.74-7.34) <0.0001
>65
(ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Female Sex
1.63
(1.54-1.72) <0.0001
1.53
(1.46-1.61) <0.0001
1.70
(1.65-1.75) <0.0001
1.41
(1.38-1.45) <0.0001
1.71
(1.63-1.80) <0.0001
Unmarried
1.09
(1.03-1.16) 0.003
1.09
(1.03-1.15) 0.002
1.09
(1.05-1.12) <0.0001
1.07
(1.05-1.10) <0.0001
1.53
(1.45-1.62) <0.0001
Region
Northeast (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Midwest

1.20
(1.09-1.33) 0.0003
1.11
(1.02-1.22) 0.02
1.26
(1.20-1.33) <0.0001
1.18
(1.13-1.23) <0.0001
1.17
(1.08-1.27) 0.0002
South

1.30
(1.19-1.43) <0.0001
1.23
(1.13-1.33) <0.0001
1.31
(1.25-1.38) <0.0001
1.24
(1.20-1.29) <0.0001
1.04
(0.96-1.12) 0.33
West

1.38
(1.25-1.52) <0.0001
1.37
(1.26-1.50) <0.0001
1.40
(1.33-1.47) <0.0001
1.44
(1.38-1.51) <0.0001
1.29
(1.19-1.40) <0.0001
Education
Less than
Highschool
0.93
(0.87-1.00) 0.04
0.92
(0.86-0.98) 0.74
0.96
(0.93-1.00) 0.05
0.83
(0.81-0.86) <0.0001
0.67
(0.63-0.72) <0.0001
Graduated
Highschool/
GED
0.87
(0.81-0.92) <0.0001
0.83
(0.78-0.88) <0.0001
0.91
(0.88-0.94) <0.0001
0.90
(0.88-0.93) <0.0001
0.75
(0.71-0.79) <0.0001
More than
Highschool (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Survey Year

2004
0.78
(0.71-0.85) <0.0001
0.77
(0.72-0.83) <0.0001
0.87
(0.75-1.00) 0.047
2005

0.76
(0.71-0.82) <0.0001
0.73
(0.68-0.77) <0.0001
0.96
(0.86-1.07) 0.44
2006
0.77
(0.71-0.84) <0.0001
0.73
(0.69-0.78) <0.0001
0.86
(0.76-0.98) 0.02
2007
0.78
(0.72-0.84) <0.0001
0.74
(0.69-0.79) <0.0001
0.95
(0.84-1.08) 0.44
2008
0.95
(0.88-1.03) 0.23
0.97
(0.91-1.04) 0.41
1.11
(0.98-1.26) 0.10

47

*aOR: adjusted Odds Ratio

2009
0.96
(0.89-1.03) 0.24
0.98
(0.92-1.04) 0.55
1.03
(0.91-1.16) 0.62
2010 (ref) (ref) (ref) (ref) (ref) (ref)
2011
1.18
(1.07-1.32) 0.002
1.07
(0.98-1.18) 0.12
0.93
(0.87-0.99) 0.03
0.94
(0.89-1.00) 0.03
1.01
(0.90-1.12) 0.90
2012

1.09
(0.98-1.21) 0.11
0.96
(0.87-1.05) 0.35
0.87
(0.81-0.83) <0.0001
0.83
(0.79-0.88) <0.0001
0.91
(0.82-1.01) 0.08
2013

1.02
(0.92-1.14) 0.70
0.93
(0.85-1.03) 0.15
0.81
(0.76-0.88) <0.0001
0.82
(0.77-0.87) <0.0001
0.77
(0.69-0.87) <0.0001
2014

0.96
(0.86-1.08) 0.52
0.90
(0.81-0.99) 0.03
0.76
(0.71-0.83) <0.0001
0.78
(0.73-0.83) <0.0001
0.77
(0.68-0.88) <0.0001
2015

0.97
(0.87-1.09) 0.66
0.91
(0.83-1.01) 0.07
0.82
(0.76-0.89) <0.0001
0.76
(0.72-0.81) <0.0001
0.81
(0.71-0.91) 0.0007
2016

0.89
(0.79-1.00) 0.05
0.89
(0.80-0.99) 0.03
0.71
(0.66-0.77) <0.0001
0.74
(0.69-0.79) <0.0001
0.82
(0.72-0.92) 0.001
2017 (ref) (ref) (ref) (ref)
0.76
(0.70-0.82) <0.0001
0.79
(0.74-0.85) <0.0001
0.94
(0.83-1.06) 0.32
2018
0.86
(0.79-0.93) 0.0002
0.87
(0.81-0.93) <0.0001
1.21
(1.07-1.37) 0.002
No Paid Work
1.30
(1.23-1.37) <0.0001
1.24
(1.18-1.31) <0.0001
1.14 (1.11-
1.18) <0.0001
1.11 (1.08-
1.14) <0.0001
1.54 (1.46-
1.62) <0.0001
Insurance
Private (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Public

1.55
(1.43-1.68)
<0.0001
1.68
(1.56-1.81) <0.0001
1.99
(1.91-2.08) <0.0001
2.05 (1.98-
2.12) <0.0001
1.74 (1.62-
1.88) <0.0001
Other
Insurance
1.19
(1.02-1.38) 0.03
1.19
(1.04-1.36) 0.009
1.35
(1.25-1.46) <0.0001
1.64 (1.55-
1.75) <0.0001
1.37 (1.20-
1.56) <0.0001
Uninsured

5.26
(4.91-5.63) <0.0001
4.26
(3.99-4.55) <0.0001
3.50
(3.37-3.64) <0.0001
4.24 (4.12-
4.38) <0.0001
3.56 (3.35-
3.79) <0.0001
Income
≤$34,999/year
3.33
(2.99-3.70) <0.0001
3.19
(2.89-3.51) <0.0001
4.15
(3.91-4.40) <0.0001
3.41 (3.27-
3.56) <0.0001
2.79 (2.55-
3.06) <0.0001
$35,000-
$74,999/year

2.21
(2.10-2.45) <0.0001
2.09
(1.91-2.29) <0.0001
2.50
(2.36-2.64) <0.0001
2.28 (2.18-
2.37) <0.0001
1.90 (1.74-
2.08) <0.0001
≥$75,000/year (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)

48
Table S11: Multivariable model of healthcare affordability and accessibility issues in adults with
liver disease
&
vs no liver disease or other chronic diseases

*aOR: Odds Ratio adjusted for age, sex, marital status, United States Census Region, education level,
survey year, employment, insurance coverage, and annual income
^CAD: Coronary Artery Disease
&
Liver Disease: liver disease includes adults who reported yes to “Ever had any chronic liver condition?”
or “Told had a liver condition, past 12 months” or “Ever told by a doctor you had cancer; what kind of
cancer…liver?” or “ Ever had Hepatitis?”

Model Outcome Variable
Unable to afford 1 of
6 Medical Services
Unable to Afford
Medications
Medical Care
Delayed
Needed but did not
get medical care
aOR*
p
value aOR*
p
value aOR*
p
value aOR*
p
value
Liver
Disease vs
No Liver
Disease
2.21 (2.09-
2.35)
(N=397,367)
)
<0.000
1
2.36 (2.20-
2.54)
(N=397,269)
<0.000
1
2.12 (1.99-
2.27)
(N=894,148)
<0.000
1
2.19 (2.04-
2.36)
(N=894,120)
<0.000
1
Liver
Disease vs
History of
Cancer
1.59 (1.48-
1.71)
(N=43,339)
<0.000
1
1.54 (1.40-
1.69)
(N=43,331)
<0.000
1
1.36 (1.25-
1.49)
(N=43,766)
<0.000
1
1.39 (1.26-
1.53)
(N=43,767)
<0.000
1
Liver
Disease vs
Emphyse
ma
1.10 (1.01-
1.20)
(N=15,438) 0.02
1.01 (0.92-
1.12)
(N=15,434) 0.77
1.06 (0.95-
1.17)
(N=15,547) 0.27
1.06 (0.95-
1.19)
(N=15,550) 0.27
Liver
Disease vs
CAD^
1.36 (1.26-
1.47)
(N=27,712)
<0.000
1
1.17 (1.06-
1.28)
(N=27,706) 0.001
1.27 (1.16-
1.40)
(N=27,957)
<0.000
1
1.27 (1.14-
1.41)
(N=27,961)
<0.000
1

49
Table S12: Post Hoc Analysis: Multivariable model of healthcare affordability and accessibility
issues in adults with liver disease vs no liver disease adjusted for race

*aOR: Odds Ratio adjusted for age, sex, marital status, United States Census Region, education level,
survey year, employment, insurance coverage, race, and annual income
^CAD: Coronary Artery Disease

Model Outcome Variable
Unable to afford 1 of
6 Medical Services
Unable to Afford
Medications
Medical Care
Delayed
Needed but did not
get medical care
aOR*
p
value aOR*
p
value aOR*
p
value aOR*
p
value
Liver
Disease vs
No Liver
Disease
2.22 (2.09-
2.35)
(N=390,327)
<0.000
1
2.38 (2.21-
2.56)
(N=390,231)
<0.000
1
2.08 (1.95-
2.23)
(N=878,978)
<0.000
1
2.19 (2.03-
2.36)
(N=878,954)
<0.000
1
Liver
Disease vs
History of
Cancer
1.98 (1.71-
2.28)
(N=36,072)
<0.000
1
2.14 (1.80-
2.55)
(N=36,067)
<0.000
1
1.77 (1.49-
2.10)
(N=36,455)
<0.000
1
1.64 (1.34-
1.99)
(N=36,450)
<0.000
1
Liver
Disease vs
Emphyse
ma
1.11 (1.02-
1.21)
(N=15,063) 0.01
1.02 (0.93-
1.13)
(N=15,059) 0.64
1.06 (0.95-
1.18)
(N=15,171) 0.29
1.07 (0.95-
1.20)
(N=15,173) 0.25
Liver
Disease vs
CAD^
1.38 (1.28-
1.49)
(N=27,182)
<0.000
1
1.18 (1.07-
1.30)
(N=27,176) 0.0007
1.28 (1.16-
1.41)
(N=27,426)
<0.000
1
1.30 (1.16-
1.44)
(N=27,428)
<0.000
1

50
Table S13: Post Hoc Analysis: Multivariable model of healthcare affordability and accessibility
issues in adults with liver disease vs no liver disease adjusted for key medical comorbidities

Model Outcome Variable
Unable to afford 1 of 6
medical services
N=304,126
Unable to afford
medications
N=304,055
Medical care delayed
N=304,887
Needed but did not get
medical care
N=304,887
aOR* p value aOR* p value aOR* p value aOR* p value
Liver Disease vs
Without Liver Disease 2.01 (1.87-2.15) <0.0001 2.00 (1.83-2.19) <0.0001 1.70 (1.57-1.85) <0.0001 1.82 (1.66-1.99) <0.0001
Age
18-39 3.15 (3.02-3.29) <0.0001 3.64 (3.41-3.87) <0.0001 2.64 (2.49-2.79) <0.0001 3.20 (2.99-3.42) <0.0001
40-49
3.87 (3.70-4.05) <0.0001 4.48 (4.20-4.78) <0.0001 3.70 (3.49-3.93) <0.0001 4.66 (4.35-4.99) <0.0001
50-64
3.22 (3.09-3.36) <0.0001 3.45 (3.25-3.65) <0.0001 3.60 (3.41-3.80) <0.0001 4.08 (3.83-4.35) <0.0001
≥65
(ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Female Sex
1.65 (1.61-1.69) <0.0001 1.75 (1.69-1.81) <0.0001 1.37 (1.33-1.41) <0.0001 1.36 (1.31-1.40) <0.0001
Unmarried
1.06 (1.04-1.09) <0.0001 1.07 (1.04-1.11) <0.0001 1.44 (1.40-1.49) <0.0001 1.40 (1.35-1.45) <0.0001
Region
Northeast (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Midwest
1.18 (1.13-1.23) <0.0001 1.22 (1.15-1.29) <0.0001 1.24 (1.18-1.30) <0.0001 1.14 (1.08-1.21) <0.0001
South
1.23 (1.18-1.28) <0.0001 1.27 (1.21-1.35) <0.0001 1.16 (1.11-1.21) <0.0001 1.24 (1.17-1.30) <0.0001
West
1.37 (1.31-1.42) <0.0001 1.10 (1.04-1.17) 0.001 1.30 (1.24-1.36) <0.0001 1.22 (1.16-1.30) <0.0001
Education
Less than Highschool 0.95 (0.92-0.99) 0.007 0.99 (0.94-1.03) 0.57 0.67 (0.64-0.70) <0.0001 0.77 (0.74-0.81) <0.0001
Graduated
Highschool/
GED 0.92 (0.90-0.95) <0.0001 0.93 (0.89-0.96) 0.0002 0.74 (0.71-0.76) <0.0001 0.81 (0.74-0.84) <0.0001
More than Highschool
(ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Survey Year
2004-2007 0.78 (0.75-0.81) <0.0001 0.85 (0.82-0.89) <0.0001 0.79 (0.76-0.83) <0.0001 0.81 (0.77-0.85) <0.0001
2008-2010 (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
2011-2018 0.88 (0.85-0.91) <0.0001 0.76 (0.74-0.79) <0.0001 0.85 (0.82-0.88) <0.0001 0.88 (0.84-0.91 <0.0001
No Paid Work 1.10 (1.07-1.12) <0.0001 1.19 (1.15-1.23) <0.0001 1.04 (1.01-1.07) 0.02 1.11 (1.08-1.15) <0.0001
Insurance Status
Private (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Public 1.95 (1.88-2.02) <0.0001 1.69 (1.60-1.77) <0.0001 1.18 (1.13-1.24) <0.0001 1.50 (1.42-1.58) <0.0001
Other Insured 1.45 (1.37-1.54) <0.0001 1.12 (1.03-1.23) 0.01 1.00 (0.92-1.08) 0.95 1.28 (1.17-1.39) <0.0001
Uninsured 4.22 (4.09-4.36) <0.0001 4.35 (4.17-4.53) <0.0001 4.88 (4.70-5.06) <0.0001 6.15 (5.90-6.42) <0.0001
Income
≤$34,999/year 3.61 (3.46-3.77) <0.0001

3.85 (3.63-4.08) <0.0001 3.70 (3.51-3.90) <0.0001 4.80 (4.47-5.15) <0.0001
$35,000-$74,999/year
2.28 (2.19-2.38) <0.0001 2.45 (2.32-2.59) <0.0001 2.35 (2.23-2.47) <0.0001 2.70 (2.52-2.89) <0.0001
≥$75,000/year (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Hypertension 1.48 (1.44-1.52) <0.0001 1.84 (1.77-1.91) <0.0001 1.39 (1.34-1.44) <0.0001 1.51 (1.45-1.57) <0.0001
Diabetes 1.47 (1.41-1.52) <0.0001 1.70 (1.61-1.78) <0.0001 1.28 (1.22-1.34) <0.0001 1.29 (1.22-1.36) <0.0001
Alcohol use
Abstinent (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)

51

*aOR: adjusted Odds Ratio

Former 1.89 (1.82-1.96) <0.0001 1.72 (1.63-1.81) <0.0001 1.64 (1.56-1.72) <0.0001 1.57 (1.49-1.65) <0.0001
Current 1.72 (1.67-1.78) <0.0001 1.59 (1.53-1.66) <0.0001 1.65 (1.58-1.71) <0.0001 1.50 (1.44-1.57) <0.0001

52
Table S14: Post Hoc Analysis: Multivariable model of healthcare affordability and accessibility
issues in adults with liver disease vs history of cancer adjusted for key medical comorbidities

Model Outcome Variable
Unable to afford 1 of 6
medical services
N=30,983
Unable to afford
medications
N=30,979
Medical care delayed
N=31,053
Needed but did not get
medical care
N=31,051
aOR* p value aOR* p value aOR* p value aOR* p value
Liver Disease vs
History of Cancer 1.51 (1.39-1.65) <0.0001 1.40 (1.26-1.56) <0.0001 1.30 (1.17-1.44) <0.0001 1.36 (1.21-1.53) <0.0001
Age
18-39 4.85 (4.23-5.56) <0.0001 5.70 (4.78-6.80) <0.0001 3.39 (2.84-4.04) <0.0001 4.27 (3.50-5.20) <0.0001
40-49
5.36 (4.73-6.07) <0.0001 6.22 (5.30-7.31) <0.0001 4.63 (3.95-5.43) <0.0001 6.21 (5.21-7.41) <0.0001
50-64
3.78 (3.45-4.15) <0.0001 3.87 (3.42-4.39) <0.0001 4.02 (3.56-4.53) <0.0001 4.42 (3.85-5.07) <0.0001
≥65
(ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Female Sex
1.62 (1.41-1.75) <0.0001 1.50 (1.36-1.65) <0.0001 1.38 (1.26-1.52) <0.0001 1.31 (1.18-1.46) <0.0001
Unmarried
1.09 (1.01-1.18) 0.03 1.09 (0.99-1.20) 0.09 1.47 (1.33-1.63) <0.0001 1.44 (1.29-1.61) <0.0001
Region
Northeast (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Midwest
1.25 (1.12-1.41) <0.0001 1.17 (1.00-1.36) 0.048 1.26 (1.09-1.46) 0.002 1.23 (1.04-1.46) 0.01
South
1.41 (1.26-1.57) <0.0001 1.27 (1.11-1.47) 0.0008 1.39 (1.21-1.60) <0.0001 1.37 (1.17-1.61) <0.0001
West
1.53 (1.36-1.72) <0.0001 1.09 (0.94-1.28) 0.26 1.54 (1.33-1.79) <0.0001 1.33 (1.12-1.59) 0.001
Education
Less than Highschool 0.99 (0.89-1.10) 0.87 1.03 (0.90-1.17) 0.70 0.76 (0.67-0.87) <0.0001 0.83 (0.72-0.95) 0.008
Graduated
Highschool/
GED 0.90 (0.83-0.99) 0.02 0.94 (0.84-1.05) 0.28 0.74 (0.66-0.82) <0.0001 0.82 (0.72-0.92) 0.001
More than Highschool
(ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Survey Year
2004-2007 0.83 (0.75-0.92) 0.0006 0.94 (0.83-1.07) 0.37 0.79 (0.76-0.83) <0.0001 0.81 (0.77-0.85) <0.0001
2008-2010 (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
2011-2018 1.00 (0.92-1.08) 0.94 0.87 (0.78-0.97) 0.01 0.85 (0.82-0.88) <0.0001 0.88 (0.84-0.91 <0.0001
No Paid Work 1.07 (0.98-1.17) 0.11 1.12 (1.00-1.25) 0.06 0.91 (0.81-1.01) 0.09 0.95 (0.84-1.07) 0.37
Insurance Status
Private (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Public 1.70 (1.56-1.86) <0.0001 1.45 (1.29-1.63) <0.0001 1.15 (1.03-1.29) 0.01 1.34 (1.18-1.53) <0.0001
Other Insured 1.46 (1.21-1.75) <0.0001 0.89 (0.68-1.15) 0.37 0.94 (0.74-1.19) 0.61 0.98 (0.74-1.30) 0.88
Uninsured 4.96 (4.36-5.64) <0.0001 4.73 (4.13-5.41) <0.0001 6.43 (5.61-7.36) <0.0001 7.59 (6.56-8.79) <0.0001
Income
≤$34,999/year 3.61 (3.46-3.77) <0.0001

4.46 (3.67-5.43) <0.0001 4.39 (3.71-5.19) <0.0001 6.21 (4.98-7.76) <0.0001
$35,000-$74,999/year
2.28 (2.19-2.38) <0.0001 2.45 (2.03-2.95) <0.0001 2.55 (2.17-2.99) <0.0001 2.91 (2.33-3.64) <0.0001
≥$75,000/year (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Hypertension 1.21 (1.12-1.31) <0.0001 1.36 (1.23-1.50) <0.0001 1.13 (1.03-1.24) 0.01 1.26 (1.13-1.40) <0.0001
Diabetes 1.31 (1.19-1.43) <0.0001 1.40 (1.25-1.57) <0.0001 1.14 (1.02-1.28) 0.02 1.10 (0.96-1.25) 0.16
Alcohol use
Abstinent (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)

53
*aOR: adjusted Odds Ratio

Former 1.74 (1.57-1.94) <0.0001 1.44 (1.26-1.65) <0.0001 1.37 (1.20-1.57) <0.0001 1.31 (1.13-1.52) <0.0001
Current 1.47 (1.33-1.63) <0.0001 1.21 (1.06-1.38) <0.0001 1.27 (1.12-1.44) 0.0002 1.19 (1.03-1.36) <0.0001

54
Table S15: Post Hoc Analysis: Multivariable model of healthcare affordability and accessibility
issues in adults with liver disease vs emphysema adjusted for key medical comorbidities

Model Outcome Variable
Unable to afford 1 of 6
medical services
N=11,275
Unable to afford
medications
N=11,274
Medical care delayed
N=11,292
Needed but did not get
medical care
N=11,295
aOR* p value aOR* p value aOR* p value aOR* p value
Liver Disease vs
Emphysema 1.15 (1.05-1.27) 0.002 1.02 (1.26-1.56) <0.0001 1.03 (0.92-1.16) 0.57 1.07 (0.94-1.22) 0.28
Age
18-39 3.09 (2.58-3.71) <0.0001 3.35 (2.70-4.17) <0.0001 2.21 (1.76-2.77) <0.0001 2.28 (1.80-2.90) <0.0001
40-49
3.84 (3.31-4.46) <0.0001 4.02 (3.34-4.83) <0.0001 3.06 (2.52-3.72) <0.0001 3.81 (3.11-4.65) <0.0001
50-64
3.00 (2.69-3.35) <0.0001 2.92 (2.52-3.39) <0.0001 2.98 (2.57-3.45) <0.0001 3.09 (2.64-3.61) <0.0001
≥65
(ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Female Sex
1.63 (1.49-1.79) <0.0001 1.50 (1.36-1.65) <0.0001 1.37 (1.23-1.52) <0.0001 1.20 (1.06-1.35) 0.003
Unmarried
1.05 (0.95-1.16) 0.37 1.04 (0.92-1.18) 0.50 1.28 (1.13-1.44) 0.0001 1.26 (1.10-1.45) 0.0009
Region
Northeast (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Midwest
1.27 (1.11-1.46) 0.0008 1.20 (1.00-1.43) 0.046 1.30 (1.10-1.54) 0.002 1.27 (1.05-1.55) 0.02
South
1.51 (1.32-1.72) <0.0001 1.31 (1.11-1.55) 0.001 1.48 (1.27-1.73) <0.0001 1.55 (1.30-1.85) <0.0001
West
1.51 (1.30-1.74) <0.0001 1.09 (0.91-1.31) 0.33 1.41 (1.19-1.67) <0.0001 1.29 (1.06-1.57) 0.01
Education
Less than Highschool 0.92 (0.82-1.04) 0.19 0.96 (0.83-1.10) 0.53 0.69 (0.60-0.79) <0.0001 0.78 (0.67-0.91) 0.001
Graduated
Highschool/
GED 0.89 (0.79-0.99) 0.03 0.91 (0.80-1.04) 0.18 0.74 (0.65-0.84) <0.0001 0.81 (0.70-0.93) 0.004
More than Highschool
(ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Survey Year
2004-2007 0.83 (0.75-0.92) 0.0006 1.06 (0.84-1.09) 0.47 0.95 (0.83-1.09) 0.50 0.99 (0.84-1.15) 0.87
2008-2010 (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
2011-2018 1.00 (0.92-1.08) 0.94 0.96 (1.15-1.46) 0.53 0.83 (0.73-0.93) 0.002 0.81 (0.70-0.92) 0.002
No Paid Work 1.06 (0.94-1.19) 0.33 1.21 (1.05-1.39) 0.009 0.95 (0.83-1.09) 0.45 1.10 (0.95-1.28) 0.22
Insurance Status
Private (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Public 1.54 (1.38-1.73) <0.0001 1.33 (1.14-1.54) 0.0002 1.00 (0.86-1.15) 0.97 1.02 (0.87-1.19) 0.85
Other Insured 1.28 (1.03-1.59) 0.02 0.82 (0.61-1.10) 0.19 0.72 (0.53-0.97) 0.03 0.78 (0.56-1.08) 0.13
Uninsured 3.99 (3.40-4.70) <0.0001 4.04 (3.40-4.79) <0.0001 1.00 (0.86-1.15) 0.97 5.83 (4.88-6.97) <0.0001
Income
≤$34,999/year 3.80 (3.16-4.59) <0.0001

2.67 (2.10-3.40) <0.0001 3.53 (2.82-4.55) <0.0001 5.65 (4.14-7.71) <0.0001
$35,000-$74,999/year
2.17 (1.81-2.60) <0.0001 1.88 (1.49-2.38) <0.0001 2.41 (1.91-3.03) <0.0001 3.10 (2.27-4.23) <0.0001
≥$75,000/year (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Hypertension 1.20 (1.09-1.32) 0.0002 1.30 (1.15-1.46) <0.0001 1.20 (1.07-1.34) 0.001 1.28 (1.13-1.45) <0.0001
Diabetes 1.12 (1.01-1.25) 0.04 1.19 (1.05-1.36) 0.006 1.21 (1.06-1.38) 0.01 1.06 (0.92-1.23) 0.42
Alcohol use
Abstinent (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)

55
*aOR: adjusted Odds Ratio

Former 1.67 (1.46-1.91) <0.0001 1.32 (1.13-1.55) 0.0007 1.26 (1.07-1.48) 0.004 1.11 (0.94-1.31) 0.24
Current 1.56 (1.37-1.78) <0.0001 1.29 (1.10-1.52) 0.002 1.35 (1.15-1.58) 0.0003 1.14 (0.97-1.35) 0.12

56
Table S16: Post Hoc Analysis: Multivariable model of healthcare affordability and accessibility
issues in adults with liver disease vs coronary artery disease adjusted for key medical comorbidities

Model Outcome Variable
Unable to afford 1 of 6
medical services
N=20,189
Unable to afford
medications
N=20,187
Medical care delayed
N=20,237
Needed but did not get
medical care
N=20,242
aOR* p value aOR* p value aOR* p value aOR* p value
Liver Disease vs
CAD^ 1.42 (1.29-1.55) <0.0001 1.24 (1.11-1.30) 0.0001 1.28 (1.14-1.44) <0.0001 1.37 (1.21-1.55) <0.0001
Age
18-39 3.31 (2.77-3.96) <0.0001 4.00 (3.23-4.97) <0.0001 2.62 (2.08-3.31) <0.0001 2.81 (2.17-3.65) <0.0001
40-49
4.27 (3.71-4.92) <0.0001 4.96 (4.22-5.85) <0.0001 3.68 (3.08-4.38) <0.0001 4.70 (3.90-5.68) <0.0001
50-64
3.28 (2.98-3.60) <0.0001 3.34 (2.95-3.79) <0.0001 3.34 (2.95-3.79) <0.0001 3.50 (3.04-4.02) <0.0001
≥65
(ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Female Sex
1.57 (1.45-1.71) <0.0001 1.48 (1.34-1.64) <0.0001 1.21 (1.09-1.34) 0.0002 1.11 (0.99-1.24) 0.07
Unmarried
1.05 (0.97-1.15) 0.24 1.13 (1.02-1.26) 0.03 1.36 (1.22-1.52) <0.0001 1.43 (1.26-1.63) <0.0001
Region
Northeast (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Midwest
1.35 (1.18-1.54) <0.0001 1.24 (1.05-1.46) 0.01 1.38 (1.17-1.63) 0.0002 1.34 (1.10-1.62) 0.003
South
1.47 (1.3-1.66) <0.0001 1.29 (1.11-1.49) 0.001 1.44 (1.34-1.68) <0.0001 1.58 (1.3-1.88) <0.0001
West
1.54 (1.35-1.76) <0.0001 1.16 (0.98-1.37) 0.09 1.37 (1.16-1.61) <0.0001 1.32 (1.09-1.60) 0.01
Education
Less than Highschool 0.90 (0.81-1.00) 0.05 0.92 (0.81-1.04) 0.18 0.75 (0.66-0.86) <0.0001 0.83 (0.72-0.96) 0.01
Graduated
Highschool/
GED 0.85 (0.77-0.94) 0.001 0.89 (0.79-1.01) 0.08 0.74 (0.66-0.84) <0.0001 0.84 (0.73-0.96) 0.01
More than Highschool
(ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Survey Year
2004-2007 0.79 (0.71-0.89) <0.0001 0.93 (0.81-1.07) 0.32 0.89 (0.76-1.03) 0.12 1.05 (0.90-1.23) 0.53
2008-2010 (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
2011-2018 1.00 (0.91-1.10) 0.97 0.88 (0.78-1.00) 0.04 0.87 (0.77-0.97) 0.02 0.90 (0.79-1.03 0.12
No Paid Work 1.02 (0.91-1.13) 0.78 1.12 (0.98-1.28) 0.11 0.95 (0.83-1.09) 0.13 0.99 (0.86-1.15) 0.92
Insurance Status
Private (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Public 1.65 (1.50-1.82) <0.0001 1.43 (1.26-1.62) <0.0001 1.20 (1.05-1.37) 0.008 1.37 (1.19-1.59) <0.0001
Other Insured 1.33 (1.09-1.62) 0.005 0.98 (0.75-1.27) 0.86 0.83 (0.64-1.08) 0.17 1.02 (0.76-1.36) 0.89
Uninsured 4.32 (3.72-5.01) <0.0001 4.59 (3.92-5.39) <0.0001 5.95 (5.08-6.97) <0.0001 7.31 (6.16-8.67) <0.0001
Income
≤$34,999/year 4.46 (3.80-5.25) <0.0001

3.49 (2.80-4.35) <0.0001 3.68 (3.00-4.51) <0.0001 4.77 (3.68-6.19) <0.0001
$35,000-$74,999/year
2.49 (2.12-2.93) <0.0001 2.39 (1.92-2.97) <0.0001 2.44 (1.97-3.02) <0.0001 2.62 (2.01-3.42) <0.0001
≥$75,000/year (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)
Hypertension 1.23 (1.12-1.34) <0.0001 1.47 (1.31-1.66) <0.0001 1.22 (1.08-1.38) 0.001 1.33 (1.16-1.52) <0.0001
Diabetes 1.26 (1.16-1.37) <0.0001 1.39 (1.25-1.55) <0.0001 1.14 (1.02-1.28) 0.02 1.07 (0.94-1.20) 0.30
Alcohol use
Abstinent (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref)

57
*aOR: adjusted Odds Ratio ^CAD: coronary artery disease

Former 1.47 (1.32-1.64) <0.0001 1.33 (1.16-1.51) <0.0001 1.31 (1.13-1.51) 0.0002 1.07 (0.94-1.20) 0.30
Current 1.33 (1.19-1.48) <0.0001 1.18 (1.04-1.35) 0.01 1.28 (1.11-1.48) 0.0005 1.10 (0.94-1.28) 0.23

58
Table S17: Cox regression hazards model of the effects of financial distress^ on mortality among
patients with liver disease

^financial distress was defined was defined as answering “yes” to questions assessing healthcare affordability
(prescription medications, mental healthcare, dental care, eyeglasses, specialist care, and follow up care) or
healthcare accessibility (delays in medical care and needing but could not afford medical care); *aHR: adjusted
Hazards Ratio

Mortality
(N=6,120)
aHR* p value
Financial Distress
1.13 (1.01-1.27) 0.03
Female Sex 0.72 (0.65-0.80) <0.0001
Region
Northeast

(ref)

(ref)
Midwest 1.27 (1.10-1.48) 0.002
South 1.20 (1.05-1.38) 0.008
West 0.98 (0.84-1.14) 0.77
Education
Less than
Highschool

1.15 (1.02-1.30)

0.03
Graduated
Highschool/
GED
1.20 (1.05-1.36) 0.006
More than
Highschool
(ref) (ref)
Insurance
Private

(ref)

(ref)
Public 1.54 (1.36 -1.74) <0.0001
Other Insurance 1.31 (1.02-1.69) 0.04
Uninsured 0.96 (0.78 -1.17) 0.66
Income
≤$34,999/year

1.73 (1.44-2.07)

<0.0001
$35,000 to
$74,999/year
1.66 (1.36-2.03) <0.0001
≥$75,000/year
(ref) (ref)
Diabetes
1.45 (1.31-1.62) <0.0001
Alcohol Use
Abstinent

(ref)

(ref)
Former
1.49 (1.29-1.71) <0.0001
Current
1.20 (1.04-1.38) 0.01

59
Table S18: Cox regression hazards models of the effects of inability to afford medical services on
mortality among patients with liver disease

*aHR: adjusted Hazards Ratio

Mortality
(N=6,107)
aHR* p value
Unable to afford 1
of 6 medical
services
1.13 (0.97-1.32) 0.11
Female Sex 0.72 (0.63-0.83) <0.0001
Region
Northeast

(ref)

(ref)
Midwest 1.26 (1.01-1.58) 0.04
South 1.19 (0.96-1.48) 0.11
West 0.97 (0.77-1.22) 0.80
Education
Less than
Highschool

1.15 (0.96-1.38)

0.13
Graduated
Highschool/
GED
1.19 (1.01-1.41) 0.04
More than
Highschool
(ref) (ref)
Insurance
Private

(ref)

(ref)
Public 1.54 (1.30-1.83) <0.0001
Other Insurance 1.31 (0.91-1.88) 0.15
Uninsured 0.97 (0.74-1.26) 0.80
Income
≤$34,999/year

1.73(1.33-2.25)

0.001
$35,000 to
$74,999/year
1.66 (1.26-2.19) 0.0003
≥$75,000/year
(ref) (ref)
Diabetes
1.46 (1.27-1.69) <0.0001
Alcohol Use
Abstinent

(ref)

(ref)
Former
1.49 (1.22-1.81) <0.0001
Current
1.19 (0.97-1.47) 0.09

60
Table S19: Cox regression hazards models of the effects of unaffordability of medications on
mortality among patients with liver disease

*aHR: adjusted Hazards Ratio

Mortality
(N=6,105)
aHR* p value
Unable to afford
medications
1.42 (1.19-1.68) <0.0001
Female Sex 0.71 (0.62-0.82) <0.0001
Region
Northeast

(ref)

(ref)
Midwest 1.27 (1.01-1.59) 0.04
South 1.18 (0.96-1.47) 0.12
West 0.97 (0.78-1.22) 0.80
Education
Less than Highschool

1.15 (0.96-1.38)

0.13
Graduated
Highschool/
GED
1.19 (1.00-1.41) 0.045
More than Highschool (ref) (ref)
Insurance
Private

(ref)

(ref)
Public 1.53 (1.29-1.82) <0.0001
Other Insurance 1.33 (0.92-1.91) 0.12
Uninsured 0.92 (0.70-1.19) 0.52
Income
≤$34,999/year

1.70 (1.31-2.20)

<0.0001
$35,000 to
$74,999/year
1.65 (1.25-2.17) 0.0004
≥$75,000/year
(ref) (ref)
Diabetes
1.45 (1.26-1.67) <0.0001
Alcohol Use
Abstinent

(ref)

(ref)
Former
1.48 (1.22-1.80) <0.0001
Current
1.19 (0.97-1.47) 0.09

61
Table S20: Cox regression hazards models of the effects of needing but not getting care on
mortality among patients with liver disease

*aHR: adjusted Hazards Ratio

Mortality
(N=6,119)
aHR* p value
Needed but did not
getting care
0.92 (0.75-1.13) 0.44
Female Sex 0.73 (0.63-0.84) <0.0001
Region
Northeast

(ref)

(ref)
Midwest 1.28 (1.02-1.60) 0.03
South 1.22 (0.99-1.51) 0.07
West 0.98 (0.78-1.23) 0.87
Education
Less than Highschool

1.14 (0.95-1.37)

0.16
Graduated Highschool/
GED
1.19 (1.00-1.41) 0.04
More than Highschool (ref) (ref)
Insurance
Private

(ref)

(ref)
Public 1.56 (1.32-1.85) <0.0001
Other Insurance 1.32 (0.92-1.90) 0.13
Uninsured 1.03 (0.79-1.36) 0.81
Income
≤$34,999/year

1.80 (1.39-2.35)

<0.0001
$35,000 to $74,999/year 1.70 (1.28-2.24) 0.0002
≥$75,000/year
(ref) (ref)
Diabetes
1.46 (1.26-1.68) <0.0001
Alcohol Use
Abstinent

(ref)

(ref)
Former
1.51 (1.24-1.84) <0.0001
Current
1.21 (0.98-1.48) 0.07

62

Table S21: Cox regression hazards models of the effects delayed care on mortality among patients
with liver disease

*aHR: adjusted Hazards Ratio

Mortality
(N=6,118)
aHR* p value
Delayed Care
1.05 (0.87-1.28) 0.59
Female Sex 0.73 (0.63-0.84) <0.0001
Region
Northeast

(ref)

(ref)
Midwest 1.28 (1.02-1.60) 0.03
South 1.22 (0.98-1.51) 0.07
West 0.98 (0.78-1.37) 0.88
Education
Less than
Highschool
1.15 (0.95-1.37) 0.14
Graduated
Highschool/
GED
1.20 (1.01-1.42) 0.04
More than
Highschool
(ref) (ref)
Insurance
Private

(ref)

(ref)
Public 1.56 (1.31-1.85) <0.0001
Other Insurance 1.32 (0.92-1.90) 0.13
Uninsured 0.99 (0.75-1.30) 0.93
Income
≤$34,999/year

1.77 (1.36-2.30)

<0.0001
$35,000 to
$74,999/year
1.68 (1.27-2.22) 0.0003
≥$75,000/year
(ref) (ref)
Diabetes
1.46 (1.26-1.68) <0.0001
Alcohol Use
Abstinent

(ref)

(ref)
Former
1.50 (1.23-1.83) <0.0001
Current
1.21 (0.98-1.48) 0.08

63
Table S22: Types of cancers reported by participants from 2004-2018

*Percentages do not sum to 100 as participants could report more than one type of cancer

Type of Cancer N
Unweighted
(%) * Weighted N
Weighted
(%)*
Bladder Cancer 1013 2.63 244810 2.67
Blood Cancer 118 0.31 42999 0.47
Bone 316 0.82 68850 0.75
Brain 281 0.73 64657 0.70
Breast 7361 19.08 1731289 18.85
Cervical 2584 6.70 597799 6.51
Colon 2394 6.21 562451 6.12
Esophagus 182 0.47 43194 0.47
Gallbladder 34 0.09 7593 0.08
Kidney 765 1.98 176156 1.92
Larynx 107 0.28 24049 0.26
Leukemia 493 1.28 1153900 12.56
Lung 1173 3.04 269252 2.93
Lymphoma 1184 3.07 287177 3.13
Melanoma 2748 7.12 676775 7.37
Oropharynx 189 0.49 44947 0.49
Ovary 963 2.50 217019 2.36
Pancreas 140 0.36 32334 0.35
Prostate 4630 12.00 1073154 11.68
Rectum 214 0.55 50194 0.55
Skin, Non-melanoma 7647 19.83 1922797 20.94
Skin cancer (unknown type) 3227 8.37 775602 8.45
Soft tissue (fat or muscle) 198 0.51 51204 0.56
Stomach 293 0.76 64385 0.70
Testis 291 0.75 71778 0.78
Pharynx 369 0.96 82015 0.89
Thyroid 967 2.51 224635 2.45
Uterus 1803 4.67 424814 4.63
Other 1806 4.68 4344402 4.73
> 3 types 84 0.22 19991 0.22

64
Appendix B: Supplementary Figures

Figure S1: Age adjusted proportion of participants reporting financial stress from 2004-2018 by
medical service type

Supplementary Figure 1: Issues with affording medical service were further stratified by type of medical
service: (A) Unable to afford eyeglasses (B) Unable to afford mental health services (C) Unable to afford
dental services (D) Unable to afford follow up (E) Unable to afford specialist care. *Unable to afford
follow up and unable to afford specialist care data only available from 2011-2017

B C
D E
A

65

Figure S2: Kaplan Meier all-cause mortality in adults with liver disease by financial distress status

Supplementary Figure 2: Kaplan Meier Curves of adults with financial distress (red) and without
financial distress (blue) are shown in this figure. Financial distress was defined was defined as answering
“yes” to questions assessing healthcare affordability (prescription medications, mental healthcare, dental
care, eyeglasses, specialist care, and follow up care) or healthcare accessibility (delays in medical care
and needing but could not afford medical care). Among adults with liver disease, all-cause age-adjusted
mortality rates were higher in adults reporting financial distress [15.4 (95% CI: 14.6-16.1) deaths per
1,000 population] vs without financial distress [13.2 (95% CI: 12.4 -14.0) per 1,000 population]
(p<0.001).

Asset Metadata

Creator Ayyala-Somayajula, Divya (author)

Core Title Healthcare affordability among adults with liver disease from 2004-2018 in the United States: a national cohort study

Contributor Electronically uploaded by the author (provenance)

School Keck School of Medicine

Degree Master of Science

Degree Program Clinical and Biomedical Investigations

Degree Conferral Date 2023-05

Publication Date 11/16/2023

Defense Date 05/16/2023

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Cirrhosis,financial burden,financial distress,financial toxicity,healthcare accessibility,OAI-PMH Harvest

Format theses (aat)

Language English

Advisor Farias, Albert (committee chair), Dodge, Jennifer L. (committee member), Lee, Brian Pei (committee member), Terraut , Norah A . (committee member)

Creator Email ayyala@usc.edu,ayyaladivya91@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC113126798

Unique identifier UC113126798

Identifier etd-AyyalaSoma-11858.pdf (filename)

Legacy Identifier etd-AyyalaSoma-11858

Document Type Thesis

Format theses (aat)

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Abstract (if available)

Abstract Background&Aims: Liver disease carries substantial morbidity and mortality, likely incurring financial distress (ie, healthcare affordability and accessibility issues), though long-term national-level data are limited.
Methods: Using the National Health Interview Survey from 2004-2018, we categorized adults based on report of liver disease and other chronic conditions linked to mortality data from the National Death Index. We estimated age-adjusted proportions of adults reporting healthcare affordability and accessibility issues. Multivariable logistic regression and cox regression assessed the association of liver disease with financial distress and financial distress with all- cause mortality, respectively.
Results: Among adults with liver disease (N=8,977) vs without liver disease (N=1,006,782); vs cancer history (N=38,570); vs coronary artery disease (N=21,510), the age-adjusted proportion reporting healthcare affordability issues was more common in adults with liver disease [medical services: 36.9% (95% CI: 36.7-37.0) vs 18.3% (18.2-18.5); 27.0% (26.8-27.2); 31.8% (31.6%- 31.9%); medication: 20.4% (20.3-20.5) vs 8.2% (8.1-8.3); 15.0% (14.9-15.1%); 20.5% (20.4%- 20.6%)] but not emphysema (N=7,937) [medical services: 43.2% (43.0%-43.3%); medication: 26.4% (26.2-26.5)]. In multivariable analysis, liver disease (vs without liver disease; vs cancer history; vs coronary artery disease) was associated with increased likelihood of reporting inability to afford medical services [aOR: 2.2 (2.1-2.4); 2.0 (1.7-2.3); 1.4 (1.3-1.5] and medications [aOR: 2.4 (2.2-2.5); 1.6 (1.3-1.9); 1.2 (1.1-1.3)], delays in medical care [aOR: 2.1
vii
(2.0-2.3); 1.8 (1.5-2.1); 1.3 (1.2-1.4)], and not receiving needed medical care [aOR: 2.2 (2.0-2.4); 1.6 (1.3-1.9); 1.3 (1.1-1.4)] . In multivariable analysis, patients with liver disease (vs emphysema), were more likely to report inability to afford medical services ([aOR: 1.1 (1.0-1.2)] only. In multivariable analysis, among adults with liver disease, financial distress (vs. without financial distress) was associated with increased all-cause mortality [aHR 1.1 (1.0-1.3)].
Conclusions: Adults with liver disease face greater financial distress than adults without liver disease, cancer, and coronary artery disease. Financial distress is associated with increased risk of all-cause mortality among adults with liver disease. Interventions to improve healthcare affordability should be prioritized in this population.