1 in 4 Cardiovascular Patients in Low Income Families Have Significant Financial Pain

Editor’s note: The following guest post is by Khurram Nassir, a cardiologist at the Yale University School of Medicine. He is the senior author of a new paper in JAMA Cardiology, “Association of Out-of-Pocket Annual Health Expenditures With Financial Hardship in Low-Income Adults With Atherosclerotic Cardiovascular Disease in the United States.”

1 in 4 Cardiovascular Patients in Low Income Families Have Significant Financial Pain

by Khurram Nassir

In recent years I have observed my own family members and friends— most of whom had insurance– struggling because of the financial stress caused by chronic cardiovascular conditions. This led me to take a step back to further consider this problem. I was surprised to learn that it has not received a lot of attention.

To better understand the scope of this problem, we used 2006 to 2015 data from a nationally representative sample of the US population to assess the proportion of annual income spent on out-of-pocket healthcare costs by families with one or members with cardiovascular disease. We defined out-of-pocket expenses greater than 20% of family income as posing ‘high financial burden” and out-of-pocket expenses greater than 40% as ‘catastrophic.” These families are at high risk for bankruptcy.

In our study, we found that one in four low-income families with family members who had CV disease had a high financial burden and one in ten were in the catastrophic range. 82% of the out-of-pocket expenses in low-income families was spent on healthcare for the family members with CVD. Overall insurance premiums and medications were responsible for more than two-thirds of these expenses.

In my view there are four main take-home messages.

First, our study sends a strong message to all stakeholders that out-of-pocket costs poses a substantial risk for financial toxicity for CVD patients and their family members and should no longer be ignored.

Second, we need to do something about this problem. We hope that these preliminary findings will lead to further insights on health and non-health consequences of financial toxicity due to substantial out of pockets costs.

Third, as physicians we cannot continue to ignore the role of ‘pricing’ in our management decisions, as clearly, they can significantly impact the financial health of the entire family of our patients. While we may not have the complete ability to influence costs for the treatment options we offer, we can at least make every possible effort to support less expensive alternatives as well as avoiding choices on our management menu that offer limited or marginal benefit.

Fourth, and most importantly, the cardiovascular community needs to have candid conversations about how best to organize our existing resources to influence national healthcare policies and limit out-of-pocket expenses for low-income families. We should insist on price transparency and this should be used to influence physician prescribing behaviors and inform patient choices. We should also support the creation of a robust network of financial assistance support programs. We should also bring a renewed focus on the adoption of upstream low-cost preventive initiatives that may diminish downstream need for more costlier treatments.

Successful implementation of these changes will be challenging, but the reward will be a significant mitigation of the financial toxicity caused by cardiovascular disease in millions of US households.


  1. Is this any sensible surprise? The lowest 25% of the lowest 25% seems like as a no surprise especially when I would assume an inherrent bias by those doing this soft data estimatimating.

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