Background: Cancer patients with Medicaid insurance have a 50% higher risk of unplanned ED admissions during systemic chemotherapy compared to commercially insured cancer patients. In a prospective study of an ePRO app and smartwatch to remotely monitor patients receiving anti-cancer therapy, we compared symptoms and biometric data among financially fragile (able vs. not to come up with $2000 in 30 days for an unexpected expense) Medicaid enrollees and commercially insured patients with solid tumor malignancies. Methods: The study was conducted at 3 community oncology practices in WA state. (ML41539, ISRCTN25569053) The ePRO had 15 common treatment-related symptoms from the PRO-CTCAE survey. 30 patients initiating systemic treatment wore a Samsung Galaxy 3 watch and completed the ePRO daily on study provided smartphones for 2 weeks. EPRO app adherence (ratio of completed to expected entries) was 91%. Smartwatch adherence (ratio of days with any biosensor data to number of days expected) was 86%. Composite symptom scores were calculated from ePRO responses using a published mapping algorithm (Range 0-3). Repeat symptoms, number of unique symptoms scores >1, and average heart rate (HR) were compared. Results: Participants’ average age was 60 (68% female; 75% no comorbidity, 45% metastatic, 10% Medicaid, 13% reported financial fragility). Treatments: chemotherapy only (56%); immunotherapy only (11%); combination therapy (33%). Financially fragile patients had significantly higher average HR, unique symptoms, and repeat symptoms (e.g., >1 day with symptoms). The average composite symptom score over 2 weeks was significantly higher for Medicaid enrollees, and trended higher for financially fragile patients. 16% of daily composite symptom scores recorded by Medicaid patients were 2 or greater, versus 7% for non-Medicaid patients (p<0.001). Conclusions: Medicaid-insured and financially fragile patients may have more adverse responses to systemic therapy compared to more advantaged patients. If supported in larger studies, the findings may have profound implications for research aimed at improving clinical management in financially disadvantaged cancer patients.