questions about the illness (USA Today et al., 2006). The American Cancer Society and CancerCare report receiving more than 100,000 requests annually for transportation so patients can get to medical appointments, pick up medications, or receive other health services. In 2003, nearly one in five (12.3 million) people with chronic conditions3 lived in families that had problems paying medical bills (May and Cunningham, 2004; Tu, 2004). Among uninsured cancer survivors, more than one in four delayed or decided not to get treatment because of its cost, and 41 percent were unable to pay for basic necessities, including food (USA Today et al., 2006). About 5 percent of the 1.5 million American families who filed for bankruptcy in 2001 reported that medical costs associated with cancer contributed to their financial problems (Himmelstein et al., 2005).
Although family and loved ones often provide substantial amounts of emotional and logistical support and hands-on personal and nursing care (valued at more than $1 billion annually) in an effort to address these needs (Hayman et al., 2001; Kotkamp-Mothes et al., 2005), they often do so at great personal cost, themselves experiencing depression, other adverse health effects, and an increased risk of premature death (Schultz and Beach, 1999; Kurtz et al., 2004). Caregivers providing support to a spouse who report strain from doing so are 63 percent more likely to die within 4 years than others their age (Schultz and Beach, 1999). The emotional distress of caregivers also can directly affect patients. Studies of partners of women with breast cancer (predominantly husbands, but also “significant others,” daughters, friends, and others) find that partners’ mental health correlates positively with the anxiety, depression, fatigue, and symptom distress of women with breast cancer and that the effects are bidirectional (Segrin et al., 2005, 2007).
The psychosocial problems described above can adversely affect health and health care in many ways. For example, a substantial literature has documented low income as a strong risk factor for disability, illness, and death (IOM, 2001; Subramanian et al., 2002). Inadequate income limits one’s ability to purchase food, medications, and health care supplies necessary for health and health care, as well as to secure necessary transportation and obtain relief from other stressors that can accompany tasks of everyday life (Kelly et al., 2006). As noted above, lack of transportation to medical appointments, the pharmacy, the grocery store, health education classes, peer support meetings, and other out-of-home health resources is common,