Health Care Equity Cannot Afford Further Delays

“Because equal rights, fair play, justice, are all like the air; we all have it or none of us has it.”

- Maya Angelou(1) interview with Academy of Achievement

Over two decades ago, the illustrious poet and historian Maya Angelou beckoned society to consider the needs of disenfranchised and minoritized people groups. As in most of her literary works, she encouraged individuals from different backgrounds and experiences to support each other’s plight for justice because true liberty could not be known unless all were afforded the same liberty. These values have been shared with many before and after her time and could not have more urgency than now.

The COVID-19 pandemic and the era of social justice have illuminated systemic differences in healthcare delivery. Underinsured populations and people of color have suffered from disproportionate burden of disease related to bias, racism, and social determinants of health.(2) These issues resonate throughout the world. Global vulnerability to COVID-19 has remained a threat through the unequitable and delayed distribution of COVID-19 vaccines,(3) contributing to SARS-CoV-2 variants and outbreaks. In this issue of JACC: Heart Failure, Thomas et al. examined systemic differences for delays in heart failure care several years prior to COVID-19.(4)

Using the U.S. Medical Expenditure Panel Survey from 2004 to 2015, Thomas et al. sought to characterize the population of patients who forwent or delayed care for heart failure by describing their demographics, reasons for forgoing/delaying care, and the fiscal impact of the delay.(4) Since heart failure prevalence is rising particularly among elderly patients, they analyzed data by age group: < 65 years and ≥ 65 years. This study was distinctly different from most studies on this topic of delays in care. Rather than designing a study centered on patient culpability for delayed care, the authors focused on social determinants of health and stratified individual reasons for forgoing/delaying care into financial and non-financial reasons.

Among a weighted sample of 1.8 million diverse racial and ethnic patients with heart failure, forgoing/delaying care was observed in 16% of the population. Factors significantly associated with forgoing/delaying care in regression analyses included: age < 65 years, lower income, uninsurance, higher number of cardiac risk factors and comorbidities. The most common reasons for forgoing/delaying care were financial reasons including: being unable to afford care, or insurance would not approve, cover, or pay for care. Among patients delaying care, financial barriers were a greater issue for the < 65 years population (60%) compared to the ≥ 65 years (47%) population. Forgoing/delaying care was not associated with risk of future hospitalization but was associated with >$8,000 higher annual total healthcare expenditures, particularly among patients ≥ 65 years. Significant differences in costs were associated with higher out of pocket expenditures in <65 years and higher inpatient plus overall expenditures in patients ≥ 65 years with the latter likely related to duration of stay and level of care.

This national study illustrated that delays in care have a societal cost. If estimates from this study are applied to the 6.5 million individuals living with heart failure in the U.S., the annual additional cost to the U.S. healthcare system for forgoing/delaying care would exceed $8.3 billion per year. The current U.S. healthcare system is unsustainable. Is it not time to take cost-saving measures that improve quality of life and extend duration of life?

Major changes in U.S. state and federal healthcare policies are indicated. Patients are not getting care due to high costs. In one single-center study of predominantly patients with low annual income, patients shared that eliminating co-pays would be one of the most desired interventions to facilitate heart failure follow-up care.(5) In a meta-synthesis regarding physician decision-making, similar concerns were raised; physicians felt that inadequate insurance led to inequitable cardiovascular care.(6) However, physicians’ concerns were related to both the patients’ costs of care and unequitable reimbursement for care across payors—leading to a specialist’s refusal to see the patient.(6)

Both universal healthcare coverage and equitable reimbursement across payors may significantly reduce systemic differences in healthcare delivery and save society money. Given the concerns of the ≥ 65 years age group in the study by Thomas et al.,(4) the current version of Medicare may be insufficient with variable coverage and costs for the different Parts. Universal healthcare coverage could ensure that patients not bear the financial burden of seeking timely care for heart failure or any other disease, meanwhile contributing to cost-savings with upstream primordial, primary, and secondary prevention of other diseases. However, reimbursement issues must also be addressed. Medicaid reimbursement varies by state but on average provides 36% of private insurance reimbursement, contributing to disparities in access to care. Equitable reimbursement across payors could ensure that physicians and healthcare systems broadly accept patients. Additional incentivization is likely needed to assure routine management of other social determinants of health and for provision of high value care.

The solution for reducing delays in healthcare seems evident, but the process of changing healthcare policy is less clear. U.S. healthcare policy changes have historically been contentious, riddled with difficulty in achieving bipartisan state and federal concordance. The stakes are too high to debate for years on end whether or not to make changes that provide equitable healthcare. Advocacy from patients and healthcare professionals is needed to elevate the concerns regarding U.S. healthcare policy. In a country with the highest gross domestic product in the world, can resources be reallocated to prioritize equitable health in the U.S.?