Costs of Atherosclerotic CVD Cripple Low-Income Families, Even With Insurance

Too many low-income families in the United States, even those with health insurance, cannot support the healthcare costs of members diagnosed with atherosclerotic cardiovascular disease (ASCVD), a new study shows.

According to an analysis of the Agency for Healthcare Research and Quality’s Medical Expenditure Panel Survey (MEPS), one-quarter of all low-income families, on a yearly basis, experience out-of-pocket expenses related to the costs of managing a family member’s ASCVD that soak up a full 20% of annual household income.

Rohan Khera, MD (UT Southwestern Medical Center, Dallas, TX), presented the study today at the Quality of Care and Outcomes Research Scientific Sessions in Arlington, VA.

In recent years, much of the research into US healthcare costs has focused on improving access to medical insurance, lead investigator Khera explained to TCTMD. What hasn’t been studied as closely is the extent of coverage provided and the amount that people have to pay above and beyond that amount. “Research hasn’t looked at what people have to pay out of pocket: insurance premiums, deductions, copayments, prescription costs, and things like wheelchairs for someone with peripheral vascular disease who can’t walk—there are so many costs that are a part of this.”

Drawing on MEPS data, Khera and colleagues assessed annual ASCVD-related costs in relation to overall household income. The definition of “low-income” was set at approximately double the US poverty threshold, thereby including families whose annual household incomes fell in the $20,000 to $25,000 range during the study period (2006 to 2015). Out-of-pocket expenses reaching 20% of the family’s income were designated “high” health expenses and those reaching at least 40% of the family’s income were deemed “catastrophic,” meaning they had the potential to swamp a family’s ability to pay for other life necessities.

Khera et al found that nearly one in 10 adults surveyed—corresponding to approximately 23 million Americans—had ASCVD, a proportion affecting approximately 15% of US families. Of these, nearly 40% were low-income households. For the cohort as a whole, median annual family out-of-pocket expenses were $2,450 and median income was $39,765. When costs were stratified according to household earnings, however, important disparities emerged. For low-income families, out-of-pocket medical expenses represented a median 6.4% of annual income, a number that fell to 5.5 % in mid- and high-income families. Moreover, the likelihood of facing annual medical costs that were “high” or “catastrophic” was threefold and ninefold higher for low-income families, as compared with families in the mid- and high-income brackets.

Maybe as a society, we can work towards making sure that people are receiving basic healthcare at a reasonable price. Rohan Khera

In a troubling nuance, families who had health insurance were more likely than families without insurance to incur out-of-pocket expenses for medical care. “That is one of the findings that we have to explore further,” Khera said. “Why are insured folks worse off than the uninsured? It’s probably because the ones that are uninsured don’t even seek care.”

According to Khera, the numbers suggest that policy provisions used when the Affordable Care Act was first drawn up, placing maximum price caps for medical expenditures, were not adequately scaled to real-world incomes and costs. “Our suggestion would be that financial out-of-pocket gaps should be scaled to the financial capacity of families,” he said.

The most common out-of-pocket expenses were insurance premiums, deductible payments, hospitalizations, and clinic visits, but also prescriptions. This last, says Khera, is an area where more could be done to make sure patients are aware of generic medications or lower-cost alternatives, and that physicians are prescribing medications that families can actually afford.

Cardiology, as a practice, tends to be focused on “expensive interventions,” as well as “flashier and shinier equipment,” Khera said.

“We should not lose sight of the fact that there are individuals who suffer from ASCVD who struggle to receive even the most basic preventive cardiac care, and they have to choose between getting that care or paying for food and the basic necessities of life,” Khera said. “Maybe as a society, we can work towards making sure that people are receiving basic healthcare at a reasonable price.”

He continued: “Any dollar spent on prevention is going to go further than a dollar spent on an expensive device.”