A Comparison of Online Medical Crowdfunding in Canada, the UK, and the US

Key Points Question Why do individuals from Canada, the UK, and the US turn to medical crowdfunding and what factors are associated with funding success? Findings In this cross-sectional study of 3396 crowdfunding campaigns designed to raise monetary donations for medical expenses, female gender, Black race, and routine care were associated with a strong fundraising disadvantage. For campaigns primarily funding treatment, routine care was overwhelmingly represented in the US (77.9%), in contrast to Canada (21.9%) and the UK (26.6%), and crowdfunding primarily funding alternative therapies (16.0%) was more common for cancer (23.5%) vs noncancer (6.5%) diagnoses. Meaning These findings suggest that there are important differences in the reasons for medical crowdfunding across the 3 countries included in this analysis and that there are racial and gender disparities in crowdfunding success.


Introduction
Crowdfunding, the online solicitation of public donations, has become an important form of financing to pay for accumulated personal health care debts. Approximately one-third of all crowdfunding campaigns seek public monetary donations intended to pay for health care-related costs. [1][2][3] The growing importance of medical crowdfunding (MCF) is reflected by trends on GoFundMe, the largest social crowdfunding platform in the world. 3,4 In 2011, medical causes raised $1.6 million on GoFundMe; in 2014, the amount had increased almost a hundredfold to $150 million and in 2016, more than $650 million. 1,3 The growing reliance of health care consumers from the US on MCF has been attributed to increasing health care costs and the lack of a publicly funded health care system. 1,5,6 However, the popularity of MCF in developed countries with universal health care such as Canada and the UK 7-10 cannot be similarly explained. To date, MCF has financed a range of therapies, including experimental and alternative therapies. [11][12][13][14] However, inequity, barriers to access, invasion of privacy, fraud, and dangerous, unproven therapies have been associated with MCF, but are poorly understood. 4,7,[15][16][17][18][19] Despite its growth and the concerns surrounding crowdfunding, there is a paucity of empirical research on MCF, including research on sociodemographic characteristics of beneficiaries and the diagnoses and treatments championed.
The objective of this study was to evaluate 3 important areas of MCF: (1) the purpose for crowdfunding in terms of diagnoses and therapies funded, (2) the characteristics of beneficiaries and campaigns, and (3) the factors associated with funding success. We selected GoFundMe as an ideal environment to study. As of 2018, the platform reportedly controlled 90% of the social crowdfunding market in the US and 80% of the global market. 20 We studied consecutive campaigns from the crowdsourcing platform in Canada, the UK, and the US, the 3 countries with the largest markets on this platform.

Statistical Analysis
We performed descriptive data analyses of all variables to evaluate trends and common characteristics of MCF in the 3 countries. Given the nongaussian populations, we used Kruskal-Wallis,

Beneficiary Demographic Characteristics and Diagnoses
Of the 3396 campaigns, 1091 originated in Canada, 1082 in the UK, and 1223 in the US. Table 1 presents the campaign characteristics, stratified by country. Most campaign beneficiaries were male

Associations With Campaign Success
Findings from multivariable regression analysis of the log-transformed funds raised per campaign are presented in Table 3. Campaign country was most strongly associated with the amount raised in the full cohort. Campaigns from Canada and the UK yielded 59.1% (95% CI, −61.0% to −57.1%; P < .001) and 78.4% (95% CI, −79.4% to −77.3%; P < .001) less funding than US campaigns, respectively.
Number of donors and fundraising goals were strongly associated with funding success (Table 3).
Facebook shares were weakly associated with funding success in the main regression model, but  when donor numbers (moderately collinear with Facebook shares) were removed from the model, Facebook shares became strongly associated with funds raised (data not shown).
The gender and race of beneficiaries were also associated with funding success. Overall, Black beneficiaries raised 11.5% less per campaign (95% CI, −19.0% to −3.2%; P = .006) with concordant but nonsignificant trend in the country-specific analyses. Overall, male beneficiaries raised 5.9%

Discussion
We examined 3396 medical campaigns from Canada, the UK, and the US, the 3 largest crowdfunding markets on GoFundMe, to characterize MCF beneficiaries, reasons for MCF, and factors associated with funding success. To our knowledge, this is the largest quantitative analysis of the MCF landscape to date. US campaigns set higher goals and raised more funds than campaigns from Canada or the UK. However, approximately two-thirds of campaigns in each country did not meet their funding goals. In the US, nearly 80% of campaigns primarily funding treatment were for routine care, whereas in Canada and the UK, funding for routine care was sought about as frequently as funding for alternative, approved but inaccessible, and experimental therapies. Campaigns for routine care were negatively associated with crowdfunding success, whereas campaigns for experimental and approved but inaccessible therapies were positively associated with funding success. Finally, we observed significant gender and racial inequities among beneficiaries.

Beneficiary Demographic Characteristics and Inequities in Crowdfunding
Crowdfunding was initially heralded as a digital safety net or a mechanism for democratizing charity where anyone could benefit. 7 However, anecdotal and empirical evidence suggests that crowdfunding may exacerbate socioeconomic inequities. 9,15,27 In our study, Black and female individuals were underrepresented in US campaigns and Black individuals were underrepresented in Canadian campaigns. In another study of 637 randomly sampled US MCF campaigns from GoFundMe, non-White beneficiaries were also significantly underrepresented, constituting only 19% of the sample although this group represents 27% of the US population. 28 Within our sample, female and Black beneficiaries raised 5.9% and 11.5% less than their male and non-Black counterparts, respectively. Similarly, in a US study of 850 campaigns for organ transplantation, female individuals raised 27% less than male individuals. 11 In a Canadian study of 319 campaigns, being a visible ethnic minority was associated with raising 15% less in funds, before adjustment for technological competency (using quantity of campaign images, videos, updates, and perks) and 6% less after adjustment. 7 Race and gender disparities reflect the pillars on which MCF is dependent: access to technology, literacy, social capital, and perception. Those with socioeconomic disadvantage are more likely to experience a digital divide that limits online participation because of a lack of access to information technology (eg, computer and internet

Limitations
This study has several limitations. First, although our data set is larger than those in previous MCF research, it is only a small subset of popular MCF campaigns. Only campaigns visible on the Discover page of GoFundMe were included in our sample, which might have led to a bias toward more successful campaigns. We adopted this approach because it allowed us to filter out dummy or unverifiable campaigns that would have made our analysis unreliable. Further work is needed to explore trends in all campaigns and other factors affecting funding success. Generalizability of our findings is limited by the use of only 1 MCF platform. It is difficult to truly ascertain the representation of MCF platforms because of a paucity of historical data and inaccessibility of proprietary information in a commercial market. Second, the veracity of the online data cannot be ensured, which restricts interpretability, but also highlights the potentially important problems of misinformation, pseudoscience, and fraud in MCF. The lack of regulation and oversight raises questions about legal and medical responsibility. Third, there are inherent limitations in manual review, especially for demographic data using only media and textual context. However, in the absence of auditable information, we believe this method provides an adequate granular view of the campaign information and demographic characteristics in MCF. Near-perfect concordance between reviewers also shows the reliability of the coded data. Moreover, we believe our approach parallels the online crowdfunding experience of a potential donor who would rely on his or her perception of a beneficiary's identity and attribute merit based on the illness narrative and media alone.

Conclusions
We provide a foundational descriptive analysis of MCF and factors associated with success in Canada, the UK, and the US, and highlight important differences in MCF trends between publicly and privately funded health care systems. Our findings also suggest that there are racial and gender disparities in the use and success of MCF. MCF directly (through platforms that promote the victim narrative) and indirectly (by rewarding these narratives with funding success) promotes the myth that gaps in health care funding are due to misfortune and exceptionality, rather than systemic failures. As such, MCF may entrench the systemic failures that led to its need. Thus, although crowdfunding has the potential to provide short-term relief from medical financial burden for a subset of patients, it may carry wider-reaching paradoxical societal effect for those most socially disadvantaged. Further research is needed to understand the social, ethical, and economic implications of MCF within each health care setting and inform policy changes that promote equitable and accessible health care through this practice.