Background: Acute myocardial infarction (AMI) and stroke represent unanticipated major healthcare events that require emergent and expensive care. Given their potential financial implications among uninsured, we sought to evaluate their rates of catastrophic healthcare expenditures (CHEs), defined as expenses beyond financial means, in a period before insurance protections in the Affordable Care Act.
Methods: In the National Inpatient Sample (2008-2012), we identified all AMI and stroke hospitalizations among uninsured adults 18-64 years of age. Patient income was modelled as a gamma distribution based on the margins of the reported income quartiles, and food expenses were estimated from US Bureau of Labor Statistics data. CHE was defined as hospitalization charges that exceeded 40% of annual income after subtracting subsistence (i.e. food) expenditure.
Results: We identified 39296 AMI (81% ≥45y, 26% women, 13% black, 38% in lowest income quartile and 12% in highest quartile) and 29182 stroke (82% ≥45y, 39% women, 26% black, 41% in lowest income quartile and 11% in highest quartile) hospitalizations among uninsured nonelderly, estimating to 188,192 and 139,687 nationally. The uninsured represent 15% of both AMI and stroke hospitalizations among nonelderly. Median hospitalization charges for AMI were $53,384 (IQR 33,282 - 84,551) and stroke were $31,218 (IQR 18,805 - 60,009). For hospitalizations in the uninsured, the posterior probability of CHE in AMI was 85% (95% credible interval [CrI] 85 - 85%), and in stroke was 75% (95% CrI 75- 75%). Low income, high comorbidity burden and urban location consistently predict elevated risk of CHE (Figure).
Conclusions: Over 1 in 8 nonelderly AMI and stroke hospitalizations are among those without insurance, and in-hospital expenditures alone can drive most of them to financial ruin. Until there is universal coverage for those without resources, catastrophic illness will remain a disabling financial threat to many Americans.