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. 2018 Aug 1;3(8):729-738.
doi: 10.1001/jamacardio.2018.1813.

Association of Out-of-Pocket Annual Health Expenditures With Financial Hardship in Low-Income Adults With Atherosclerotic Cardiovascular Disease in the United States

Rohan Khera  1 , Javier Valero-Elizondo  2 , Victor Okunrintemi  2 , Anshul Saxena  2 , Sandeep R Das  1 , James A de Lemos  1 , Harlan M Krumholz  3   4   5 , Khurram Nasir  4   5
Affiliations

Association of Out-of-Pocket Annual Health Expenditures With Financial Hardship in Low-Income Adults With Atherosclerotic Cardiovascular Disease in the United States

Rohan Khera et al. JAMA Cardiol. .

Abstract

Importance: Health insurance is effective in preventing financial hardship from unexpected major health care events. However, it is also essential to assess whether vulnerable patients, particularly those from low-income families, are adequately protected from longitudinal health care costs for common chronic conditions such as atherosclerotic cardiovascular disease (ASCVD).

Objective: To examine the annual burden of total out-of-pocket health expenses among low-income families that included a member with ASCVD.

Design, setting, and participants: In this cross-sectional study of the Medical Expenditure Panel Survey from January 2006 through December 2015, all families with 1 or more members with ASCVD were identified. Families were classified as low income if they had an income under 200% of the federal poverty limit. Analyses began December 2017.

Main outcomes and measures: Total annual inflation-adjusted out-of-pocket expenses, inclusive of insurance premiums, for all patients with ASCVD. We compared these expenses against annual family incomes. Out-of-pocket expenses of more than 20% and more than 40% of family income defined high and catastrophic financial burden, respectively.

Results: We identified 22 521 adults with ASCVD, represented in 20 600 families in the Medical Expenditure Panel Survey. They correspond to an annual estimated 23 million or 9.9% of US adults with a mean (SE) age of 65 (0.2) years and included 10.9 million women (47.1%). They were represented in 21 million or 15% of US families. Of these, 8.2 million families (39%) were low income. The mean annual family income was $57 143 (95% CI, $55 377-$58 909), and the mean out-of-pocket expense was $4415 (95% CI, $3735-$3976). While financial burden from health expenses decreased throughout the study, even in 2014 and 2015, low-income families had 3-fold higher odds than mid/high-income families of high financial burden (21.4% vs 7.6%; OR, 3.31; 95% CI, 2.55-4.31) and 9-fold 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. 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.

Conclusions and relevance: One in 4 low-income families with a member with ASCVD, including those with insurance coverage, experience a high financial burden, and 1 in 10 experience a catastrophic financial burden due to cumulative out-of-pocket health care expenses. To alleviate economic disparities, policy interventions must extend focus to improving not only access, but also quality of coverage, particularly for low-income families.

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Conflict of interest statement

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Krumholz is a recipient of research agreements from Medtronic and Johnson & Johnson (Janssen), through Yale, to develop methods of clinical trial data sharing; is chair of the Cardiac Scientific Advisory Board for UnitedHealth; is the founder of Hugo, a personal health information platform; is a participant/participant representative of the IBM Watson Health Life Sciences Board; is a member of the Advisory Board for Element Science; is a member of the Physician Advisory Board for Aetna; works under contract with the Centers for Medicare & Medicaid Services to develop and maintain measures of hospital performance measures; and is the recipient of a grant from Medtronic and the Food and Drug Administration, through Yale, to develop methods for postmarket surveillance of medical devices. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Trends in Rates of High and Catastrophic Financial Burden From Out-of-Pocket Health Expenditures by Income Group
Figure 2.
Figure 2.. Trends in Rates of High and Catastrophic Financial Burden From Out-of-Pocket Health Expenditures by Access to Insurance
Figure 3.
Figure 3.. Trends in Rates of High and Catastrophic Financial Burden From Out-of-Pocket Health Expenditures by Insurance Group
See this image and copyright information in PMC

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