One in Eight US Patients With MI or Stroke Under Age 65 Are Uninsured, Face Catastrophic Costs

ANAHEIM, CA—An analysis looking at the financial impact of acute MI and stroke in uninsured patients under age 65 in the United States may serve as a cautionary tale for lawmakers hoping to roll back or repeal Obamacare.

In the years following the 2010 implementation of the Affordable Care Act (ACA), the percentage of uninsured Americans dropped by 40%, with the majority of gains made among adults 18-65 years of age—those not covered under preexisting Medicare. It’s in this age group that nearly half of all MIs and 40% of all strokes occur, according to Rohan Khera, MD (University of Texas Southwestern Medical Center, Dallas), who presented that data here at the American Heart Association 2017 Scientific Sessions. The analysis was also published simultaneously as a research letter in Circulation.

Medical expenses, he noted, are the number one cause of bankruptcy in the United States, and uninsured individuals are particularly vulnerable.

For the study, Khera with co-PI Jonathan C. Hong, MD (University of British Columbia, Vancouver, Canada), and colleagues examined the proportion of stroke and acute MI hospitalizations among adults 18-65 in the United States who had no medical insurance between 2008 and 2012. Data was extracted from the National Inpatient Sample and modeled to reflect the entire US population, yielding nearly 40,000 acute MI patients and 30,000 stroke patients who were uninsured at the time of their event, or roughly 15% of the population experiencing stroke or MI.

Phrased differently, the numbers suggest that “over one in eight patients were uninsured,” Khera said. “Numerically, this represents 190,000 AMI and 140,000 stroke hospitalizations among uninsured in the US during this 5-year period.”

Household expenses were estimated using neighborhood income quartiles and subjected to additional modelling to account for variations within quintiles. “Post-subsistence” income was then calculated by subtracting estimated food expenses from annual income. “Catastrophic” health expenditures were defined as any hospitalization cost higher than 40% of post-subsistence income.

Based on the different models and subsequent calculations, Khera and colleagues estimate that a full 85% of uninsured acute MI patients and 75% of uninsured stroke patients were at risk for a catastrophic expense. Even when the ratios of charges-to-income were tweaked (allowing for the possibility that hospitalization costs might surpass 60%, 80%, or 100% of income), investigators found that more than half of all uninsured patients could still be expected to face a catastrophic expense.

In other words, the “vast majority” of hospitalizations for acute MI and stroke pose “a substantial financial burden,” said Khera. “Insurance mechanisms to cover devastating major healthcare expenses should be explored.”

In a separate presentation during a Sunday morning press conference, Hong shared an analysis using the same modelling over the same pre-ACA period, but looking at uninsured CABG patients. Here again, one out of 11 nonelderly CABG patients were estimated to have been uninsured during this 5-year period and more than 96% could be expected to experience a catastrophic health event.

A ‘Troubling’ Turn

After Obamacare went into effect, the number of uninsured Americans fell from 14.6% to 8.6%, Khera noted.

And while Khera, Hong, and colleagues have not repeated their modelling to account for falling numbers of uninsured adults over the ensuing years, Khera acknowledged that there are concerns about the “troubling trend” in US politics that could ultimately drive up the number of health-related catastrophic costs.

“With the fact that 23 million more Americans gained insurance coverage [under the ACA], and a portion of them would have suffered major expenses as a result of MI, stroke, or otherwise, we would expect that that number would have gone down,” he said. “If a repeal or replace effort [takes] place, we would expect that 27-29 million Americans would lose insurance coverage.”

Of note, the study only looked at costs of hospitalizations. “I think it’s safe to assume that recurring costs after hospitalization and [during] recovery after a cardiac event would also contribute to the greater likelihood of continued bankruptcies and the economic impact on these patients, particularly in secondary prevention,” Hong told TCTMD.

There are also the added costs related to lost productivity, Khera chimed in, since many of these patients would not return swiftly to the workforce.