The current US healthcare system fails to protect a substantial proportion of nonelderly patients with atherosclerotic cardiovascular disease (ASCVD) from financial difficulties, according to the results of a study published in the Journal of the American College of Cardiology.

Javier Valero-Elizondo, MD, MPH, from the Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut, and colleagues used 5 years of data from 2013 through 2017 from the National Health Interview Survey to investigate the degree of financial distress, food insecurity, and cost-related medication nonadherence among nonelderly US adults with ASCVD.

The authors identified 6160 nonelderly individuals who reported having ASCVD. Of these, 2741 (45.1%) belonged to families reporting financial hardship from medical bills. This represents a population of 3.9 million individuals in the United States. Of this population, 1229 (representing 1.64 million) nonelderly adults with ASCVD (18.9%) stated they were unable to pay medical bills.

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Individuals who reported an inability to pay medical bills had higher levels of high financial distress (odds ratio [OR], 3.60), food insecurity (OR, 2.89), and cost-related medication nonadherence (OR, 3.39). Lower-income individuals were more likely to face financial hardship from medical bills and to be unable to pay medical bills than higher-income individuals (OR, 1.34 and 2.24, respectively). Likewise, persons who were uninsured were more likely to face financial hardship because of medical bills or to be unable to pay them than persons who were insured (OR, 1.86 and 3.27, respectively).

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The authors noted that 1 in 5 patients with ASCVD were unable to pay medical bills, and at least one-third of patients with ASCVD were in families that experienced financial hardship from medical bills and were at risk for its consequences, including food insecurity and cost-related medication nonadherence.

The study is limited by the self-reported nature of the data; its cross-sectional design of the study, which prohibits determining causality; the fact that the question regarding financial hardship assessed the family as a whole and may have reflected costs other than those for ASCVD; and the inconclusiveness of the data regarding whether the financial distress resulted from long-term bills for routine maintenance or from a catastrophic event.

The authors concluded that the current insurance structure falls short of providing protection from financial hardship for many families, and they argued that the current trend of diverting a greater proportion of cost sharing by payers will exacerbate this problem.


Valero-Elizondo J, Khera R, Saxena A, et al. Financial hardship from medical bills among nonelderly U.S. adults with atherosclerotic cardiovascular disease. J Am Coll Cardiol. 2019;73(6):727-732.