Heart Disease Exacts High Financial Toll on Low-Income Families

Megan Brooks

July 03, 2018

Healthcare bills related to atherosclerotic cardiovascular disease (ASCVD) could spell financial ruin for low-income families, even those who have health insurance, according to a new cross-sectional study.

After examining a nationally representative sample of US families, researchers found that one in four low-income families with a member with ASCVD experience a high financial burden owing to out-of-pocket healthcare costs associated with treating the chronic condition. High financial burden was defined as 20% of a family's annual postsubsistence income.

In addition, almost 1 in 10 low income families suffer from "catastrophic" financial burden by spending more than 40% of their annual income on medical expenditures — "levels that are associated with real risk for bankruptcy and financial ruin for these families," senior author Khurram Nasir, MD, from Yale University's Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut, told theheart.org | Medscape Cardiology.

Financial hardship is "well recognized" as a major risk in consideration of high costs associated with management of patients with cancer, yet "surprisingly, this issue has not been on the cardiovascular community's radar in recent years," said Nasir. This study sends a "strong message to all stakeholders that financial hardship is a real phenomenon" among families with ASCVD.

The study was published online July 3 in JAMA Cardiology.

Using data from the Medical Expenditure Panel Survey from January 2006 through December 2015, the researchers identified 22,521 adults with ASCVD, represented in 20,600 families. They corresponded to an annual estimated 23 million US adults (9.9%). The mean annual family income was $57,143 and mean out-of-pocket health expense was $4415.

Although financial hardship from out-of-pocket health expenses decreased throughout the study, even in 2014 and 2015, low-income families had a threefold higher likelihood than middle- and high-income families of high financial burden (21.4% vs 7.6%; odds ratio [OR], 3.31; 95% confidence interval [CI], 2.55 - 4.31) and a ninefold higher odds of catastrophic financial burden (9.8% vs 1.2%; OR, 9.35; 95% CI, 5.39 - 16.20), representing nearly 2 million low-income families nationally, the investigators report.

"Further, even among the insured, 1.6 million low-income families (21.8%) experienced high financial burden and 721,000 low-income families (9.8%) experienced catastrophic out-of-pocket health care expenses in 2014 and 2015," they further report.

Nasir said he hopes these findings launch a "broader discussion" within the cardiovascular community to not only shed light on the problem but also find solutions.  

"Unfortunately, private insurance — which one would expect to cushion from financial risk — actually further exacerbated the out-of-pocket costs, including medical premiums, copayments, deductibles, and essential medications," Nasir added in a news release.  "This was especially true for self-purchased private insurance, which may provide less comprehensive and equitable coverage than that afforded by most employer-based group healthcare insurance. In comparison, those covered via public insurances, especially among low-income families, were the least likely to suffer from financial hardships at the family level," Nasir said.

"There are many people who are not only suffering from the disruption, pain, and suffering associated with an acute illness or chronic condition but also dealing with the financial toxicity of the associated healthcare costs to them and their families," Harlan Krumholz, MD, director of Yale CORE, who worked on the study, said in a news release.

"We're doing this research to put some numbers to this issue so that it can't be ignored. These numbers will influence the policy debates about healthcare, for when people say 'We're doing well enough,' or 'Things have gotten better,' we can show with these numbers that, no, we're not nearly where we need to be," said Krumholz.

Reached for comment, Adam Powell, PhD, president of Payer+Provider Syndicate, a Boston-based consulting firm specializing in operational challenges faced by health insurance companies and hospitals, said, "Given that the authors included insurance premiums in their measure of out-of-pocket expenses, it is not surprising that they found that out-of-pocket healthcare expenses represent a substantial financial burden for many American families with one or more members with ASCVD."

"While health plans feature maximum out-of-pocket clauses, which limit patients' out-of-pocket exposure to the cost of care, the limits can still be quite high," Powell told theheart.org | Medscape Cardiology.

"Although there are a number of programs in place to reduce the financial exposure of low-income Americans to healthcare costs, these findings show that the level of exposure low-income Americans with ASCVD face is still substantial," added Powell.

"The bright spot in the story," he said, "is that out-of-pocket costs, while large, steadily decreased for low-income families between 2006 and 2015. As total medical costs for low-income families with members with ASCVD increased during this period, it suggests that cost exposure for the families was reduced. While things appear to have gotten better over time, there is still clearly room to go in ensuring financial access to care."

The study was partly funded by the National Heart, Lung, and Blood Institute and the National Center for Advancing Translational Sciences of the National Institutes of Health.  Nasir has no relevant disclosures.  Krumholz reports ties to Johnson & Johnson (Janssen), United Health, Hugo, IBM Watson, Element Science, and Aetna Inc. Powell reports having no relevant disclosures.

JAMA Cardiol. Published online July 3, 2018. Full text

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