No Major Progress on Making CV Care More Affordable: JACC Stats

The high cost of care for cardiovascular conditions is causing some patients to skip out on needed medications or appointments to save money, and which can potentially lead to worse outcomes, according to several papers in a special JACC stats issue published last week. More needs to be done, their authors say, to address that barrier.

Along with other papers on trends in exercise, sleep duration, dietary quality, and healthcare access and utilization, the latest update on cardiovascular statistics affirms, among other findings, that a decades-long decline in CV mortality started to slow, or even reverse, across multiple conditions roughly 15 years ago.

JACC Editor-in-Chief Harlan Krumholz, MD (Yale New Haven Hospital), who co-wrote some of the data reports, has called the leveling off of CV mortality rates a “disquieting plateau.”

The hope is that this special stats issue will spark a national conversation about the interplay between spending on CV care and outcomes, Krumholz told TCTMD. The cardiology community took credit for the fall in mortality rates over several decades, so the onus should be on that same community to figure out why progress has stalled despite high levels of spending, he said.

Rishi Wadhera, MD (Beth Israel Deaconess Medical Center, Boston, MA), senior author of the paper looking at healthcare expenditures and an author on the healthcare affordability paper, told TCTMD, “The bottom line is that patients with cardiovascular conditions are paying more and getting no relief, and that’s been true for a decade and a half.”

In this JACC issue, investigators looked into how much working-age adults with CVD or related risk factors and private health insurance, who often end up paying more than individuals covered by public insurance, are spending on healthcare. Over time, inflation-adjusted healthcare expenditures increased, mostly due to rising insurance premiums, with no relief in terms of the proportion of patients experiencing financial burdens from medical bills.

Another paper showed that total direct cardiovascular spending, including out-of-pocket costs and payments from private and public insurers, has continued to rise, even as CV mortality rates leveled off.

And a third explored how these trends have impacted measures of healthcare affordability. Though there was actually some reduction in the proportion of patients with cost-related medical nonadherence over a recent 6-year span, the percentage of patients delaying or forgoing care due to financial concerns didn’t change, with many patients continuing to make tough healthcare decisions based on the amount of money they have in the bank.

An Overlooked Population

In their paper on healthcare expenditures, Wadhera, along with lead author Smaraki Dash, MD (Beth Israel Deaconess Medical Center), and colleagues, looked at working-age adults with CVD and/or related risk factors.

Most of the research and policy questions about the affordability of cardiovascular care have focused on Medicare beneficiaries, Wadhera noted. “We focus on working-age adults with cardiovascular conditions because they’re a large and genuinely overlooked population. They’re typically privately insured, they’re in their peak earning years, they’re often supporting families, and they just have fewer policy protections than older adults on Medicare do.”

He added, “We’ve essentially been having a conversation about the affordability crisis in the United States, but we’ve left out a huge part of the population that’s struggling the most. This was an attempt to shine a light on that group.”

The investigators examined data covering 2007 to 2022 from the Medical Expenditure Panel Survey (MEPS). The analysis included privately insured adults ages 25 to 64 years who had CVD (ie, coronary artery disease, angina pectoris, MI, peripheral artery disease, or stroke) and/or related risk factors like hypertension, diabetes, hyperlipidemia, and TIA. There were 4,036 adults (weighted mean age 49.6 years; 47.4% women) in 2007 and 3,085 (weighted mean age 49.8 years; 45.6% women) in 2022.

The people who are the sickest are also the ones who are least able to afford to be sick. Rishi Wadhera

During the study period, inflation-adjusted healthcare expenditures, which incorporated patient contributions to insurance premiums plus out-of-pocket spending on medical services and prescription drugs, increased from $4,813 to $5,304 (P < 0.01), with a temporary dip during the COVID-19 pandemic. That increase was driven by a rise in insurance premiums ($3,389 to $3,919; P < 0.001), whereas out-of-pocket costs were relatively unchanged ($1,424 to $1,384; P = 0.69).

The proportion of patients for whom healthcare spending represented a financial burden (more than 10% of their income) remained around 34% throughout the study, with no significant change over time. The percentage with a catastrophic burden (more than 40% of income) was 10.8% in 2007 and 9.2% in 2022 (P = 0.06).

“What we found particularly striking is despite major health policy reforms over this period, including the Affordable Care Act and expansions in insurance coverage, we haven’t really moved the needle on improving the financial burden of healthcare for working-age families in the United States,” Wadhera said, noting that “the financial burden that we documented doesn’t just strain household budgets, it drives people away from the care they need to stay healthy.”

Affording Healthcare Remains a Challenge

In the analysis of healthcare affordability, led by Rishi Shah and Adith Arun, BS (both from Yale New Haven Hospital, CT), the investigators examined changes in how cost considerations were affecting adherence to medications and receipt of care across groups defined by atherosclerotic cardiovascular disease (ASCVD) status, race/ethnicity, and income using data from the National Health Interview Survey 2019-2024.

The analysis included 172,434 adults (weighted mean age 48.1 years; 51.5% women) who were asked whether they had delayed or skipped medical care due to cost or had experienced cost-related medication nonadherence (ie, skipping doses, delaying prescription fills, taking fewer medications than prescribed, or not getting drugs) over the past year.

In 2024, 11.7% of participants reported cost-related medical nonadherence, including 11.6% of those without ASCVD and 12.6% of those with ASCVD. Overall, there was a modest decline in this proportion between 2019 and 2021, followed by a leveling off.

Nonadherence varied according to race/ethnicity and income level. In 2024, it was least likely among Asian individuals (7.4%) and highest in those reporting “other” race (14.7%), and it ranged from 5.9% among those whose income was 500% or more above the federal poverty level to 16.1% among those who fell below the poverty threshold.

In terms of delaying or forgoing care due to cost, there were similar rates irrespective of ASCVD status, fluctuating between 7.5% and 11.6% during the study period. Disparities by race/ethnicity and income were seen for this outcome as well.

“We know that when patients have to pay more out of pocket, particularly those who have cardiometabolic risk factors or cardiovascular conditions, they are less likely to adhere to medications and they are more likely to forego important care that they need to stay healthy,” Wadhera said, adding that this report “really captures the implications of high out-of-pocket costs or rising out-of-pocket costs for everyday Americans.”

CV Spending No Longer Tracks With Outcomes

Arun, along with Kushal Kadakia, MD (Massachusetts General Hospital, Boston), and Krumholz, took a broader view of the economics of cardiovascular care in the US. Here, they examined trends in age-adjusted CVD mortality and total direct CV spending—incorporating out-of-pocket costs for patients and payments from private insurers, Medicare, Medicaid and other sources—between 2000 and 2022 using the Centers for Disease Control and Prevention’s WONDER database and the household component of the MEPS.

Over the entire study period, the age-adjusted CVD-related mortality rate declined by a relative 34% from 343.1 per 100,000 people in 2000 to 224.3 per 100,000 in 2022. As prior research has shown, however, there was little decline after 2011.

But despite the slowing of gains in outcomes, the total direct cost of CVD care increased steadily, rising by 212.3% from $70.5 billion in 2000 to $220.2 billion in 2022.

“The divergence between rising spending and stagnating mortality raises fundamental questions about how resources are being deployed and what is needed to resume progress in cardiovascular health,” the authors write.

What Needs to Be Done?

Wadhera said that from a regulatory standpoint, “if you’re a US policymaker and you’re worried about working-age Americans skipping care, forgoing care, and not taking their medications because healthcare costs are just taking up too much of their income, I think the first point of intervention that you need to think about is the high and rising burden of health insurance premiums for this population.”

Younger people still in the workforce stand to gain the most from early identification and treatment of cardiometabolic risk factors and from seeing a doctor before they develop catastrophic cardiovascular events, Wadhera stressed.

“I think it’s worth highlighting that when healthcare becomes unaffordable, people have to make impossible choices. They delay seeing a doctor. They skip follow-up appointments. They avoid the emergency room even when they know something’s wrong because they’re afraid of a big bill,” he said. “When you’re worried about how you’re going to pay your rent or put food on the table, managing a chronic condition like cardiovascular disease becomes very challenging.”

The financial concerns are especially acute for individuals with lower incomes or more complex or advanced CVD, Wadhera added. “The people who are the sickest are also the ones who are least able to afford to be sick. That inequity is embedded in how we finance healthcare in this country, and it’s not going to resolve itself without a deliberate policy intervention.”