The electricity cost burden of durable medical equipment in the United States

Abstract

Those who rely on durable medical equipment (DME) for their health are more likely to be energy insecure and face higher energy burdens than those who do not. In this article, we evaluate the costs of electricity to run DMEs. We find that the average cost across the most common types of high-frequency DMEs–including oxygen concentrators, continuous positive airway pressure machines, and peritoneal kidney dialysis machines–is between $120 and $333 per year, depending on device size and usage frequency. Some DMEs can cost more than $700 per year to operate, which is an increase of over 40% above the average household bill, and well over that in in states with higher electricity prices. We conclude with a discussion of how public policy can address this challenge through tighter disconnection protections and more expansive health insurance coverage.

Supplementary Information

The online version contains supplementary material available at 10.1038/s41598-024-82464-x.

The market in the United States for home health care assistive devices, and particularly durable medical equipment (DME), is large and growing. With a projected increase in the home medical equipment market from $43.3 billion in 2022 to $64.8 billion in 2027¹, it is likely that total expenditures for both the purchase and the operation of these devices will rise. The use of these devices makes households dependent on electricity^2,3, and can substantially increase household energy expenditures, since DMEs can require large amounts of electricity to operate. For those households that are energy insecure and already face difficulty in paying their energy bills, the use of DMEs has the potential to exacerbate this insecurity.

Several studies have found that an important correlate of energy insecurity and utility shut-offs is when a member of the household relies on an electronic medical device^4–6. A study conducted during the COVID-19 pandemic found that the relative likelihood of disconnection is four times greater for electronic medical device users compared to non-users, even controlling for income and other household demographics as well as COVID-related health and economic impacts⁵. Since running many DMEs requires electricity, their operations can raise a household’s energy burden. For example, in the first study to the authors’ knowledge to calculate the cost of electricity operations of DME devices, the authors focused exclusively on an oxygen concentrator, the most common DME in the United States^7,8. They found the annual cost to run this device in the average state is $322⁹. For those patients who are multi-morbid and need to use more than one machine, one should expect electricity costs to be even higher. In the case of a household already facing difficulty in covering its electricity bills, even a modest increase can result in the household struggling to pay its bills, and may ultimately lead to a disconnection.

Energy insecurity, also referred to as energy poverty, is considered an overlooked social determinant of health¹⁰. Studies confirm that households that experience energy insecurity are more likely to also experience mental and physical health conditions such as asthma and poor sleep¹¹, and, as news coverage reveals, is also correlated with mortality¹². Over half of all low-income households engage in coping strategies to pay their energy bills and avoid disconnection¹³, including carrying debt, using risky temperature strategies such as opening an oven for space heat or running a space heater, or forgoing expenses on other essential items like food or healthcare^6,10. These coping efforts can also lead to severe health and development consequences.

Building on the previous study that quantified the cost of running a single DME, the oxygen concentrator⁷, here we evaluate the costs of running a range of all popular in-home DMEs. We focus on the eleven most common types of durable medical equipment used in the United States. Using the most recent electricity price data¹⁴, we calculate the average annual cost of operating each device. Total annual estimates that we derive of DME energy expenditures range from less than a dollar for an IV pump in a state like Washington, to over $500 for running an oxygen concentrator all day in a state like Hawaii, depending on the device and usage frequency. The average annual cost across the high-frequency usage devices listed in Table 1—including continuous positive airway pressure (CPAP) machines, bilevel positive airway pressure (BiPAP) devices, feeding pumps, peritoneal kidney dialysis, ventilators, and oxygen concentrators—for mid- to high-powered devices used 24 h a day is $242–333 and $120–166 if run for 12 h a day. As we argue, these estimates reveal the importance of financial support, such as government incentives or medical insurance, for budget-constrained households that must run DMEs and rely on them for their long-term health. They also reveal the importance of considering energy costs and energy behavior in medical fields.

Results

We focus on the most common DMEs that use electricity either through plugging into a wall outlet or rechargeable battery packs: oxygen concentrator, peritoneal home dialysis, ventilator, CPAP, bilevel positive airway pressure (BiPAP), nebulizer, mobility scooter, hospital bed, enteral feeding pump, infusion pump, and suction machine. We derive information for each device on upfront cost, wattage, and hourly use from various sources including brochures and manuals, company websites like Philips^15–20, ResMed^21–25, Baxter^26–29, Pride Mobility^30,31, and Covidien³², and phone calls to manufacturing companies, and informally cross-checked with a group of practicing medical professionals via email communication. For those devices missing wattage assumptions (indicated in Table 1 with an asterisk), we calculate power (in Watts) by multiplying AC voltage (VAC) and current (Amp) and assume the power factor to be 1. We present additional information about mid-range upfront cost and brand in Appendix A.

Table 1.

Detailed annual operational costs based on wattage and usage for devices.

	Higher Frequency Usage, by Day					Lower Frequency Usage, by Day
		8 h	12 h	24 h			0.5 h	1 h	2 h
Oxygen concentrator	120W15	$47.86	$71.80	$143.59	Nebulizer	50W34	$1.25	$2.49	$4.99
	350W16	$139.61	$209.41	$418.82		110W35	$2.74	$5.48	$10.97
	600W*36	$239.32	$358.98	$717.97		204W*20	$5.09	$10.17	$20.34
Continuous positive airway pressure (CPAP)γ	53W21	$21.14	$31.71	$63.42	Power scooter	792W*30	$19.74	$39.49	$78.98
	80W18	$31.91	$47.86	$95.73		960W*31	$23.93	$47.86	$95.73
	104W22	$41.48	$62.22	$124.45		1800W*37	$44.87	$89.75	$179.49
Bilevel positive airway pressure (BiPAP) γ	53W23	$21.14	$31.71	$63.42	Hospital bed	300W29	$7.48	$14.96	$29.92
	80W 17	$31.91	$47.86	$95.73		960W*28	$23.93	$47.86	$95.73
	104W24	$41.48	$62.22	$124.45		1200W*27	29.92	59.83	119.66
Ventilator	71W19	$27.92	$41.88	$83.76	IV pump	15W38	$0.37	$0.75	$1.50
	90W25	$35.90	$53.85	$107.70		20W*39	$0.50	$1.00	$1.99
	120W25	$47.86	$71.80	$143.59		40W40	$1.00	$1.99	$3.99
Peritoneal kidney dialysisγ	100W26	$39.89	$59.83	$119.66	Suction machine	70W41	$1.75	$3.49	$6.98
	600W26	$239.32	$358.92	$717.97		90W42	$2.24	$4.49	$8.97
	700W43	$279.21	$418.82	$837.63		180W44	$4.49	$8.97	$17.95
Feeding pump	9W*32	$3.59	$5.38	$10.77	Average	Low	$6.12	$12.24	$24.47
	12W*32	$4.79	$7.18	$14.36		Medium	$10.67	$21.34	$42.68
	40W*45	$15.95	$23.93	$47.86		High	$17.07	$34.14	$68.29
Average	Low	$26.92	$40.39	$80.77
	Medium	$80.57	$120.85	$241.72
	High	$110.88	$166.33	$332.66

Notes: ^γ While these are devices that are commonly used for long durations of time, it would be rare for one to use them a full 24 h each day; ^* DME missing wattage assumptions so we generated size using voltage and current.

For each machine, we converted the rated wattage to kilowatt, then multiplied it by the time typically in use or charge, extended that across the full year, as well as the average price of electricity per kWh (2021). We use the national price for the main estimates, as presented in Table 1 below, and the state prices for estimates that vary by state, as presented in Fig. 1 below. The average national and individual state price of electricity comes from the U.S. Energy Information Administration¹⁴.

Fig. 1.

Annual cost of running life-saving devices in U.S. (2021)

Our analysis assumes a volumetric fixed electricity cost in each state, with no variation by time of day. We omit other operation costs that similarly vary by technology and usage, such as water costs³³, but encourage future studies to expand on our analysis and include these other costs.

In Table 1, we present the estimated electricity costs associated with a range of power and time of use of the devices, using the national average price of electricity. For larger, more frequently used devices, we present estimates for 8, 12, and 24 hour of drawing electricity per day, noting that users are not consistent in how often they run these devices, since it depends on the severity of their conditions. We also present a cost analysis of these higher frequency usage devices across increments of 2 hour in the Appendix B. For smaller and less frequently used devices, we present estimates for 1/2, 1, and 2 h, respectively. We similarly show the costs associated with these lower-frequency usage devices across increments of 30 minutes in Appendix C.

Given the variability in use and size of these devices, one should expect the range of costs. Estimates range from lower wattage devices such as suction machines at about $1.75 to $17.95 in electricity costs per year to much higher-powered machines such as peritoneal kidney dialysis machines at about $39.89 to $837.63. The average annual cost across the high-frequency usage devices for mid- to high-powered devices used 24 h a day is $242–333 and $120–166 for 12 h a day. Several of the devices have the potential to add more than $50 to one’s monthly electricity bill over the course of the year. To put this figure in context, the average residential electricity monthly bill in the United States in 2021 was $121⁴⁶, so an additional $50 per month in electricity would increase the bill by 40%. Those devices that cost over $700 to run increase one’s bill by a much higher percentage. Running a mid-range oxygen concentrator, peritoneal kidney dialysis machine, and ventilator for 24 h a day would raise an average household’s electricity bill by about 29%, 49%, and 7% respectively annually; running them for only 8 h a day would raise bills by 10%, 16%, and 2%. When compared across type and power consumption, operational prices for concentrators and dialysis machines can go above $850 a year as compared to only close to tens of dollars for IV pumps, nebulizers, and suction machines. For those who rely on multiple devices at once, the costs are of course additive.

In Table 2, we present the average upfront cost of the mid-range model of these devices, using the brands identified in Appendix A, and a comparison between the upfront cost and one year of operating these devices, presented as a percentage. In some cases, especially those with high upfront costs such as the ventilator, the cost of operation is a small fraction of total Costs. In other cases, such as with an oxygen concentrator, power scooter, or IV pump, the cost of operating the device for just one year is high vis-à-vis the upfront costs. While insurance may cover the full or a portion of the upfront cost of these devices, it does not cover the electricity operating costs, even in cases when the electricity costs quickly add up to the equivalent of the upfront costs after just a few years of use.

Table 2.

DME upfront costs vs. operational electricity costs, as a percentage.

DME	Upfront cost	12 h	24 h
Oxygen concentrator	$1,049	20%	40%
CPAP machine	$1,249	4%	8%
BiPAP machine	$3,499	1%	3%
Ventilator	$12,000	0%	1%
Peritoneal kidney dialysis	$56,500	1%	1%
Feeding pump	$493	1%	3%
Nebulizer	$150	4%	7%
Power scooter/wheelchair	$500	10%	19%
Hospital bed	$1,850	3%	5%
IV pump	$20	5%	10%
Suction machine	$229	2%	4%

In Fig. 1, we present the cost of using three devices—oxygen concentrators (Panel A), peritoneal kidney dialysis (Panel B), and ventilators (Panel C)—across different states. We use mid-range power consumption, mid-range hours of usage, and state-specific electricity prices to calculate these estimates. The resulting estimates simply scale by electricity price, of course, but the exercise is helpful for understanding the variation in operational costs across geography. Given the high electricity costs of Hawaii, California, Massachusetts, Rhode Island, and Connecticut, these states have the higher operational costs for all these devices (dark green states). Hawaii, Massachusetts, and California have the highest operational costs of $880, $601, and $600 per annum for peritoneal kidney dialysis. Future analyses could seek to overlay such cost estimates with the geographic distribution of DME use, as scholars have done with extreme weather risk⁴⁷, to obtain aggregate estimates of electricity expenditures by region.

When comparing the monthly bills for residents in various states across the U.S. to the cost of running a mid-range ventilator for 24 h, residents in Hawaii, California and Massachusetts pay more than 10% more on their bills each month. Similarly, to run an oxygen concentrator at home, residents in these three states pay more than 40% more on their bills each month.

Discussion

Healthcare affordability is a significant concern for society, as evident in several current debates (e.g., healthcare price transparency, affordability questions about insurance premiums, and medical bankruptcy, among other topics). Cost sharing in medical care is reduced through many government programs so that patients face lower or zero medical care costs. For DMEs this is in the form of insurance that covers the out-of-pocket upfront or rental costs of the device. These medical devices, however, unlike other forms of healthcare, involve additional out-of-pocket costs from electricity consumption. As we have argued in this article, electricity needs can contribute a substantial additional cost and are particularly burdensome for low-income families. Furthermore, the social insurer—often Medicaid or Medicare—does not cover these electricity costs, which might lead to situations where expensive and potentially life-saving devices, accessed for free or very low cost, may go unused because of the cost of electricity.

Such outcomes should be understood and addressed by policymakers. Yet, this has not historically been an area where policy discussions can occur since, to date, there have been no credible estimates of the energy needs associated with a range of medical devices. This analysis has sought to address this need by providing such estimates that can help inform policy discussions.

It is essential to recognize and document the challenge households face in paying for the electricity needed to operate DMEs and thus access full medical care. It is also important to design public policy and program solutions that address this challenge directly. One possible policy to address energy insecurity of medically compromised individuals who require DMEs is utility disconnection protections. While all but five states offer disconnection protections for those with medical conditions⁴⁸, few specify any requirements pertaining to reliance on DMEs. Moreover, many of those existing serious illness protections do not adequately protect those using DMEs. For example, many of them can only be invoked or renewed for limited periods of time, require a doctor to certify that the underlying medical condition is life-threatening (which may not be true for many with DME), still require partial or deferred payments from the customer, or require burdensome proof of low-income status⁴⁹. States could more explicitly protect those with DMEs, by removing existing barriers to asserting protection against termination.

Beyond disconnection protections, another potential policy is to help patients who cannot afford the additional energy burden to defray the cost of running their medical devices. The electricity costs of a DME are generally absent in discussions of healthcare affordability. While health insurance is designed to protect patients from financial burdens associated with illness, this hidden energy cost of medical supplies, which is not covered by insurance, could yield substantial out-of-pocket spending for low-income patients. This may lead patients not to use these devices as often as recommended, representing a lost opportunity to improve health. Medicare and Medicaid in several states are beginning to provide more flexibility for covering a greater range of items. For example, some states are allowing Medicaid Managed Care Organizations to cover air conditioners for patients with asthma, medical transport for patients, utility deposit fees, and meals;⁵⁰ and the federal government allows Medicare Advantage to offer similar benefits to patients. None of these programs currently cover the electricity costs of DME or of electricity consuming benefits offered through their social determinants of health (SDOH) programs. A careful cost-benefit approach to covering DME electricity costs under insurance programs would take into account the potential improved health, the reduced mental strain from financial worries, as well as potential increases in Medicare spending if patients are elastic in their demand for DME with respect to the operation costs (electricity) of the DME. As there is an increase in the consumption of these devices, more careful consideration should be devoted to possible insurance policy coverage of these ‘hidden’ out-of-pocket costs of DME.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

S.C. and S.B. led the analysis. All authors contributed to the idea formation, the analysis work, and the writing of the text.

Data availability

The datasets used and analyzed during the current study available from the corresponding author on reasonable request.

Declarations

Competing interests

Peter Kahn works for Sanofi, a healthcare company, in addition to his role at Yale University.Sanya Carley has no competing interests to declare. Shreya Bansal has no competing interests to declare. Charlie Harak has no competing interests to declare. David Konisky has no competing interests to declare. Kosali Simon has no competing interests to declare.