In this prospective, multi-site, AMI registry, we found that nearly 2 in every 5 patients were uninsured or were insured but reported financial concerns in accessing care. These patients, in turn, were more likely to delay seeking emergency care for an AMI, even after extensive adjustment for clinical, social, and psychological factors. These findings underscore important consequences from inadequate health care insurance coverage for the substantial number of Americans experiencing AMIs and suggest that efforts to reduce prehospital delay times may have limited impact without first ensuring that access to health insurance is improved and that financial concerns are addressed in patients who seek emergency care.
To our knowledge, this study is the first to demonstrate an association between the lack of health care insurance and prehospital delays during AMI. While this observation may seem intuitive, uninsured patients have not been previously found to have higher rates of prehospital delays.31, 32
Our findings on insurance status may have differed from earlier studies because of a higher proportion of uninsured patients in this contemporary registry. Moreover, our study’s use of patient interviews, rather than administrative data, allowed us to adjust for patients’ health status and important social and psychological confounders to better clarify the independent association of insurance status with prehospital delays in AMI.
Perhaps most importantly, our study was also able to evaluate the impact of financial concerns in accessing medical care among those with insurance on delays in seeking care. Through detailed, structured interviews, we identified individuals who reported financial burdens related to use of health care services despite the presence of insurance. This process utilized a patient’s perspective and is a significant advance from the use of coarse administrative data sources. Remarkably, more than half of all insured patients with financial concerns in our study had fee-for-service or health maintenance organization insurance plans. Thus, having private health care insurance did not guarantee use of health care services that were essential for these patients, perhaps because they perceived them as unaffordable in the face of competing financial demands.
Several studies have previously described patients who forego routine medical treatment because of high cost burden as the ‘underinsured’.15-17, 19, 33
Such avoidance of care due to costs was associated with more angina, poorer health status, and higher rates of rehospitalization.19, 33
While underinsurance has not been well-studied to date, this group represents a growing U.S. patient population susceptible to disparities in care for emergent conditions like AMI. In this study, we were able to show an association between financial concerns in accessing care among insured patients and delays to hospital presentation. However, we did not have sufficiently detailed information on patients’ health insurance plans or preferences in decision-making to determine whether perceived financial concerns among those with insurance were due to underinsurance or personal choices to forego broader insurance coverage plans for lower premiums. To further inform health-policy decision-making, however, additional studies are required to determine whether and which aspects of underinsurance—high out-of-pocket health care costs (copayments, coinsurance, deductibles), low lifetime health benefit ceilings, or lack of catastrophic or stop-loss provisions—may be responsible for perceived cost burden.
The finding that uninsured and insured patients with financial concerns about accessing medical treatment delay seeking care for potentially fatal but treatable medical conditions raises particular concerns, as the majority of these families in the U.S. are the ‘working poor’, often with 2 full-time workers in the household.1, 4, 34
The inability to address patients’ concerns about costs of emergency care may, in part, explain the failure of prior intervention studies to reduce prehospital delay times during AMI.14, 35
Moreover, because black and female patients are more likely to face financial concerns in accessing medical care despite insurance or be uninsured,19
addressing insurance coverage has the potential to reduce disparities in care for these vulnerable populations. In fact, we found that previously described associations between race, age, and sex—which are largely non-modifiable demographic characteristics—with prehospital delays7, 9
were substantially attenuated after adjustment for insurance status and other social, psychological, and clinical variables in this study.
It is likely that uninsured patients and insured patients with financial concerns about accessing care not only delay seeking care for AMI, but also for other common medical conditions, such as stroke, pneumonia, and appendicitis.36
As a result, interventions that broaden and ensure the affordability of health insurance coverage in the U.S. may reduce times to presentation for all emergent medical conditions. Such policy interventions are particularly important in light of a recent analysis that found that as many as 45,000 deaths annually in the U.S. are attributable to lack of health insurance alone.37
These interventions would also address critics of EMTALA, who argue that the legislation’s unfunded mandate over the past 2 decades has imposed undue economic burdens on hospitals and paradoxically decreased the availability of emergency care services that the law was intended to promote.38, 39
Finally, our study also provides insights into other novel, and potentially modifiable, patient characteristics associated with prehospital delays during AMI that are distinct from previously described—but often non-modifiable—predictors, such as age, sex, race, diabetes mellitus, and absence of chest pain. Specifically, we found an association between lower educational level, recent angina, and depressive symptoms with prehospital delays. In contrast, high levels of perceived stress were associated with shorter times to hospital presentation. Since large community-based education programs for AMI in the U.S. have not been previously successful in reducing times from symptom onset to hospital presentation,14, 35, 40
future educational public health efforts may need to address these specific predictors, in addition to insurance status, in developing new interventions.
Our study should be interpreted in the context of the following limitations. Delay times were not documented in the medical records in 12% of patients and we did not have a mechanism to validate delay times reported in the medical records. However, documenting delay times by patients’ recall has been widely employed in other studies and rates of missing delay times in this study did not differ from prior studies.7, 9
Importantly, rates of missing delay times were similar across insurance groups and were accounted for in our propensity-weighted analyses.
Second, while our models adjusted for an extensive number of demographic, social, clinical, and psychological factors, we did not have information on other factors that may have influenced prehospital delay times, including the use of Emergency Medical Services for hospital transport, geographical distance from site of ischemic symptom occurrence to presenting hospital, and traffic patterns in urban and rural areas. Moreover, we did not have information on each patient’s annual hospital expenditures, deductibles, medical co-payments, and covered medical benefits to directly assess underinsurance, nor did we have information on annual household income and expenses to determine the extent to which perceived financial concerns about accessing care were due to limited disposable income rather than patients’ conscious choices to forego broad insurance coverage in exchange for lower premiums.
Third, while we found that the uninsured and the insured with financial concerns were associated with delays, nearly 2 in 5 insured patients without financial concerns also had delays to hospital presentation exceeding 6 hours. This suggests that other patient factors accounted for prehospital delays, and improving health insurance coverage, while important, is but one component in a comprehensive strategy to reduce times to hospital presentation during AMI. Fourth, our cohort was drawn from a sample of 24 urban hospitals throughout the U.S. and may not be generalizable to other sites or regions. Lastly, our study cohort does not include patients who never sought care or who died before hospitalization. Since we found that uninsured and insured patients with financial concerns had greater delays in seeking treatment, our estimates are likely to be conservative estimates of the association between insurance status and prehospital delay for AMI.
In conclusion, in this large multicenter registry, we found that patients with either no insurance or insured patients with financial concerns about accessing medical treatment were more likely to delay seeking emergency care for AMI, a commonly occurring condition. Efforts to reduce prehospital delays for AMI, as well as for other emergency conditions, may have limited impact unless U.S. health care insurance coverage is extended and improved.