When the cure becomes a symptom: the financial burden of American health care

Planning for retirement, saving for a child’s university education, for a house or a car, or to build a rainy-day fund are all part of responsible financial planning. But nobody plans to break an arm, get sick, or receive a cancer diagnosis. These situations are stressful enough for the patient and their family. But in America, the cost of healthcare can mean these unexpected situations can derail years of financial planning and leave many patients facing a loss of savings, a lower quality of life, or even bankruptcy. And that’s not just a problem for the patient’s mental health. Doctors want the best possible treatment available for their patients, but some are noticing that ignoring the financial burden of treatment is actually harmful to patient’s physical health and can impede their recovery.

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For the Americans lucky enough to have health insurance and to need it only for minor illnesses, injuries, or routine appointments, insurance is an adequate financial protection and out-of-pocket costs don’t make a big impact on daily life. But for those unfortunate enough to experience a cancer diagnosis or a serious, chronic illness that leaves them going in and out of hospitals on a regular basis, even a good insurance plan and adequate savings isn’t enough to shield from financial insecurity.

A recent study of the portion of the American population that uses the health care system the most, conducted jointly by The New York Times, the Commonwealth Fund and the Harvard T.H. Chan School of Public Health, is shedding light on the challenges faced by those who spend the most time and money navigating America’s health care system. Survey respondents had all been hospitalized at least twice within the past two years and had seen at least three doctors in that time period, and many had chronic conditions that require regular medical care. Among those with insurance, over 20% reported struggling to pay for basic necessities as a result of their health costs. While those with no insurance faced the most serious financial difficulties, many of the insured reported their insurance was not enough. Out of pocket spending for those with health insurance has increased by 50% since 2010, according to Aon Hewitt. Deductibles, or the amount patients pay for covered treatments before insurance kicks in, have risen almost 7 times as fast as wages in the last five years. For the sickest Americans, this effect is even more devastating. They face higher co-pays and deductibles, and were most likely to be recommended treatments their insurance refuses to cover. Many are unsure what their insurance will or won’t pay for, and the resulting financial burden can be devastating. Even worse, health insurance in America is often provided by employers, and those that have to cut back on work because of their illness or that of a family member are at risk of losing their insurance. Fifty-three percent of survey respondents said they had to cut back on work as a result of illness, resulting in financial difficulties. Tristan Berger, who was born with spina bifida and is now 47, is one of them. ‘You sit there every month trying to figure out what bill to pay: Do you pay the hospital bill or do you pay the utility bill? There’s no savings. We’re part of that percentage of America that are one paycheck from being destitute.’

Cancer patients are among the most affected by this ‘financial toxicity.’ A study from Washington state showed that cancer patients were 2.65 times more likely to go bankrupt than the general public. Younger cancer patients had a 2-5 times higher risk of bankruptcy than those over 65, who are eligible for Medicare or Social Security. A 2013 study found that nearly half of insured cancer patients cut back on spending on food or clothing or went into their savings to pay for treatment. Cancer drugs are exorbitantly expensive, and as the out-of-pocket cost of these pills increase, patients are more likely to delay or stop drug therapy.  Another recent study published in Cancer journal showed that patients with three or more financial problems had clinically significant differences in physical health, and that people with any type of financial problem had significant differences in mental health, including high rates of depression.

These stressors are often unrecognized by doctors; 2/3 of seriously ill patients said their doctors had never discussed the cost of their care, and financial burdens are often difficult or embarrassing for patients to bring up in appointments. But more doctors are starting to treat these financial burdens as a side-effect or even a symptom of cancer or other chronic medical problems. Scott Ramsey, a physician and health economist based at Fred Hutchinson Cancer Research Center in Seattle believes ‘when people are diagnosed, it behooves the provider to assess their financial risk […] to find out if they’re at risk, and if they are, to be very aggressive with getting them to financial planning, to patient assistance programs to reduce their likelihood of having financial devastation.’ Khurram Nasir, physician and associate professor of medicine at Yale University, recognized the struggles of his patients who were struggling to pay for care and sometimes cutting back on food or skipping pills as a result. ‘When I started realizing this, I took it upon myself as a responsibility to talk to my patients about these issues.’

Even when patients make a full recovery, the financial consequences can last a lifetime; many end up depleting their savings or go into debt to pay medical bills. Wages are lost, as legislation in the United States does not guarantee much wage insurance, disability or sick leave, leading to a significant reduction in earnings that can take years to recover from. Health should not be tied to ability to pay, but unfortunately that is the case in America currently, even for those with insurance. When the cure worsens the disease through negative mental and physical health effects, it is time to recognize that something in the American health care system needs to change. There needs to be a re-evaluation of the way health care is billed and the methods used by insurers to determine coverage. In the meantime, though, doctors should recognize, as some are beginning to, that financial considerations cannot be ignored as side effects of treatment any longer.

If you are interested in this topic, the New York Times has published a powerful list of quotes from American readers detailing the ways health care costs have negatively impacted their lives: https://www.nytimes.com/interactive/2016/01/11/upshot/12up-medicaldebt.html?module=inline

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