Financial Toxicity of Acute Cardiovascular Disease in India

The developing world has experienced an unprecedented epidemiologic transition with an accelerating epidemic of noncommunicable diseases.1 Among these, the rising burden of cardiovascular disease has met poorly equipped health systems to create a perfect storm. Not only has cardiovascular disease become the leading cause of morbidity and mortality in the developing world,1 its meteoric rise poses an extraordinary financial risk to patients, their families, and the overburdened health systems. However, despite this threat, the financial implications of cardiovascular disease, particularly of unanticipated major cardiovascular events, remain poorly understood in the developing world. Mohanan and colleagues2 shed light on the financial outcomes of patients in the 30 days following a hospitalization for acute myocardial infarction (AMI) in a cohort of patients with AMI in the Indian state of Kerala. More than half (56%) of the 2114 participants in the study reported a health care expenditure that exceeded 40% of the annual postsubsistence income, that is, income after food-related expenses. Expenses beyond this threshold can potentially lead to financial ruin and are therefore categorized as catastrophic health expenses.3 Notably, more than 90% of costs were secondary to short-term inpatient care. One in 10 individuals even reported coping with these expenses through loans. Although the study was limited by its focus on a selected patient population and self-reported income and expenses, the magnitude of financial hardship identified in this study advances our understanding of the unmistakable financial adversity posed by acute cardiovascular disease. The current study also identified a protective association with health insurance, with 4-fold higher odds of adverse financial outcomes among those without health insurance, relative to the quarter of the overall population with AMI with access to insurance. A notable observation is that despite a national health insurance program that has been in place in India since 2008 for major unexpected health care events, disproportionately relying on out-of-pocket costs places patients and their families at significant financial risk. The authors posit their observations to support wider access to health insurance coverage in India. Although a focus on wider access to health insurance is likely to counter some of the financial challenges of health care services, a deeper evaluation of their observations offers important insights into the current status of the complex interplay of health insurance coverage and socioeconomic status in India, offering potential future opportunities worthy of further discussion. First, as shown in Table 1 of the article by Mohanan et al,2 patients with AMI who had health insurance in India were unique in that their household income was only half of those with insurance—a significant contrast with the United States, where access to health insurance is a sign of affluence.3 The insurance programs in India, particularly the Rashtriya Swasthya Bima Yojana, a tax-financed national insurance program, however, have mainly focused on providing coverage for inpatient care for individuals and family members below the poverty line.2 The program, which as of 2016 covered more than 160 million people, has incentivized an investment in tertiary or specialized care in rural areas and prompted reductions in catastrophic health spending. The middle class, which may lack resources to protect itself from the financial distress of major unexpected health events but may not qualify for insurance protections under this program, continue to be vulnerable to the catastrophic financial effects of health care.4 + Related article