Health Care Equity Cannot Afford Further Delays

Khadijah Breathett, MD, MS


JACC Heart Fail. 2021;9(10):720-721. 

"Because equal rights, fair play, justice, are all like the air; we all have it or none of us has it."
—Maya Angelou, [1] interview with Academy of Achievement

More than 2 decades ago, the illustrious poet and historian Maya Angelou beckoned society to consider the needs of disenfranchised and minoritized peoples. As in most of her literary works, she encouraged individuals from different backgrounds and experiences to support each other's flight for justice because true liberty could not be known unless all were afforded the same liberty. These values have been shared with many before and after her time and could not have more urgency than now.

The coronavirus disease-2019 (COVID-19) pandemic and the era of social justice have illuminated systemic differences in health care delivery. Underinsured populations and people of color have suffered from disproportionate burden of disease related to bias, racism, and social determinants of health.[2] These issues resonate throughout the world. Global vulnerability to COVID-19 has remained a threat through the unequitable and delayed distribution of COVID-19 vaccines,[3] thereby contributing to severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) variants and outbreaks. In this issue of JACC: Heart Failure, Thomas et al[4] examined systemic differences for delays in heart failure care several years before COVID-19.

Using the U.S. Medical Expenditure Panel Survey from 2004 to 2015, Thomas et al[4] sought to characterize the group of patients who forwent or delayed care for heart failure by describing their demographics, reasons for forgoing or delaying care, and the fiscal impact of the delay. Because heart failure prevalence is rising, particularly among older adult patients, Thomas et al[4] analyzed data by age group: <65 years and ≥65 years. This study was distinctly different from most studies on this topic of delays in care. Rather than designing a study centered on patient culpability for delayed care, Thomas et al[4] focused on social determinants of health and stratified individual reasons for forgoing or delaying care into financial and nonfinancial reasons.

Among a weighted sample of 1.8 million racially and ethnically diverse patients with heart failure, forgoing or delaying care was observed in 16% of the group. Factors significantly associated with forgoing or delaying care in regression analyses included age <65 years, lower income, lack of insurance, and higher number of cardiac risk factors and comorbidities. The most common reasons for forgoing or delaying care were financial, including being unable to afford care or having insurance that would not approve, cover, or pay for care. Among patients delaying care, financial barriers were a greater issue for the group aged <65 years (60%) compared with the group aged ≥65 years (47%). Forgoing or delaying care was not associated with risk of future hospitalization but was associated with >$8,000 higher annual total health care expenditures, particularly among patients aged ≥65 years. Significant differences in costs were associated with higher out-of-pocket expenditures in patients aged <65 years and higher inpatient and overall expenditures in patients aged ≥65 years, with the latter likely related to duration of stay and level of care.

This national study illustrated that delays in care have a societal cost. If estimates from this study are applied to the 6.5 million individuals living with heart failure in the United States, the annual additional cost to the U.S. health care system for forgoing or delaying care would exceed $8.3 billion per year. The current U.S. health care system is unsustainable. Is it not time to take cost-saving measures that improve quality of life and extend duration of life?

Major changes in U.S. state and federal health care policies are indicated. Patients are not receiving care because of high costs. In 1 single-center study of predominantly patients with low annual income, patients shared that eliminating copayments would be 1 of the most desired interventions to facilitate heart failure follow-up care.[5] In a meta-synthesis of physician decision making, similar concerns were raised; physicians believed that inadequate insurance led to inequitable cardiovascular care.[6] However, physicians' concerns were related to both the patients' costs of care and the unequitable reimbursement for care across payers—leading to a specialist's refusal to see the patient.[6]

Both universal health care coverage and equitable reimbursement across payers may significantly reduce systemic differences in health care delivery and save society money. Given the concerns of the ≥65-year age group in the study by Thomas et al,[4] the current version of Medicare may be insufficient, with variable coverage and costs for the different parts. Universal health care coverage could ensure that patients would not bear the financial burden of seeking timely care for heart failure or any other disease, meanwhile contributing to cost savings with upstream primordial, primary, and secondary prevention of other diseases. However, reimbursement issues must also be addressed. Medicaid reimbursement varies by state but on average provides 36% of private insurance reimbursement, thus contributing to disparities in access to care. Equitable reimbursement across payers could ensure that physicians and health care systems broadly accept patients. Additional incentivization is likely needed to ensure routine management of other social determinants of health and for provision of high-value care.

The solution for reducing delays in health care seems evident, but the process of changing health care policy is less clear. U.S. health care policy changes have historically been contentious, riddled with difficulty in achieving bipartisan state and federal concordance. The stakes are too high to debate for years on end whether to make changes that provide equitable health care. Advocacy from patients and health care professionals is needed to elevate the concerns regarding U.S. health care policy. In a country with the highest gross domestic product in the world, can resources be reallocated to prioritize equitable health in the United States?