A troubled health system lets Americans with heart failure fall into financial ruin, according to a new analysis of health spending.

The study, published May 16 in the Journal of the American Heart Association, estimates that 236,471 families in the U.S. will experience a high financial burden and 75,997 families will be at risk of financial disaster because they're trying to pay for heart failure treatment. Over 5.4 million people in the U.S. have heart failure each year, a chronic condition in which the heart stops pumping blood at normal levels.

In the study of 788 families captured in the Agency of Healthcare Research and Quality's Medical Expenditure Panel Survey from 2014 to 2018, researchers found that these families spent an average of $4,423 on out-of-pocket health care expenses in a year. Fourteen percent of families spent more than 20% of their annual post-food income on their health, while 5% of families spent over 40% of their income on health expenses — a level of spending the World Health Organization calls "catastrophic burden." Low-income people suffered disproportionate financial strain; their odds of catastrophic burden were 14 times higher than middle- and high-income families'.

The paper lays out empirical evidence of a problem that one of the authors sees in his cardiology practice. "I ask people about challenges with paying for their medication, and if they feel being unable to pay for medications will make them not be able to take them at all, we look at alternatives," said Rohan Khera, an assistant professor at Yale School of Medicine. "Some patients opt to not get the highest level of care. Those are tough decisions that we unfortunately have to make in our day-to-day practice. You want to not ration out care, which some of these patients are doing on their own end."

The study found that people on Medicare — the national health insurance program that covers people over 64 and some younger people with disabilities — were spending over $1,000 a year out of pocket on critical medications.

"There should be broader coverage, but the coverage lags behind the evidence-based or the clinical practice," Khera said. "They are just pricey medications, and even with partial coverage, it ends up being a lot of money for people."

Khera said these medications, which sometimes cost people hundreds of dollars each month, are critical. 

"There are several medications required for controlling the disease and preventing death, and stopping some of them can result in immediate harm — people end up requiring hospitalizations," he said. "If people stop, say, their dapagliflozin, they may not see an acute deterioration in their clinical status, but these drugs influence life expectancy. They shorten their life, essentially, by not taking these medications."

It was clear that among families in the study, financial burden varied depending on income level: For half of low-income families, the biggest spending category was medications, while only 28% of higher-income families spent the most money on medications. Middle- and high-income people spent more on insurance premiums than low-income people — $5,442 on average. Low-income people spent $2,698 on premiums. Fourteen percent of low-income families were spending the most money on premiums, but 43% of higher-income families were.

The Agency of Healthcare Research and Quality's annual Medical Expenditure Panel Survey asks about 15,000 families, including an oversampling of Black, Hispanic and Asian people, about health and medical expenses. The survey does not include institutionalized people, which, Khera said, means that, "Some of the highest-risk groups, especially among those at homeless shelters or those who are incarcerated, they're definitely not included. For them, these are maybe even larger challenges."

The researchers took total family income for each year, which could include wages, Social Security and veteran payments. Low-income families were those with an annual income less than 200% of the federal poverty limit; middle- and high-income people had an income over 200% of the federal poverty limit. In 2019, 200% of the federal poverty guideline for a two-person household was $32,920. 

Of the families, 37% were classified as low-income. 

Eight percent of middle- and high-income families had a high burden from health costs, and 1% had a catastrophic burden. For low-income families, 24% experienced a high burden, while 10% were catastrophically burdened.

The study may have understated what low-income families are going through because those families probably chose not to cut corners where they could, Khera said: "We can definitely infer from some of the earlier studies that individuals tend to defer care or opt for lower-quality care or opt for not taking some health care advice because of cost. That deferring of cost is probably more prominent in low-income individuals."

The study initially had 834 families with at least one member with heart failure to analyze. However, to generate a more conservative estimate of financial burden, the researchers dropped 46 families who would have had no income after subtracting the modest typical food costs for their income bracket suggested by the Bureau of Labor Statistics.

Only 15 families in the survey were uninsured, which the researchers defined as anyone who had at least one month without coverage.

The researchers wrote that this was evidence that, "Insurance continues to provide inadequate coverage for patients in this population with substantial health care needs." They noted that privately insured people were twice as likely as publicly insured people to be highly burdened, largely because of insurance premiums; meanwhile, publicly insured people had poor medication coverage, which drove the biggest share of their spending on health. 

The issue demands a policy response, Khera and his co-authors said; they suggested one solution could be anchoring maximum spending limits to income.

"The data that we have are captured on an annual basis, but heart failure is a chronic disease, and so families that encounter high expenses one year are likely to encounter high expenses the next year," Khera told The Academic Times. "They are likely to incur the same sort of burden year after year, and the burden's likely to grow, especially because the expenses tend to grow over time in heart failure."

The paper, "Out‐of‐pocket annual health expenditures and financial toxicity from healthcare costs in patients with heart failure in the United States," published May 16 in the Journal of the American Heart Association, was authored by Stephen Y. Wang, Yale-New Haven Hospital; Javier Valero-Elizondo, Hyeon-Ju Ali, Miguel Cainzos-Achirica and Khurram Nasir, Houston Methodist Hospital; Ambarish Pandey, University of Texas Southwestern Medical Center; and Harlan M. Krumholz and Rohan Khera, Yale School of Medicine and Yale-New Haven Hospital.