Author + information
- Published online December 31, 2018.
- Khadijah Breathett, MD, MS∗ ()
- ↵∗Address for correspondence:
Dr. Khadijah Breathett, Division of Cardiology, University of Arizona, 1501 North Campbell Avenue, Tucson, Arizona 85724.
Health care insurance is a prerequisite for heart transplantation in the United States (1); medical necessity alone is not sufficient for heart transplant listing. Financial means are also required. With 10% of nonelderly U.S. residents remaining uninsured (2), many patients are faced with a rate-limiting step when considering advanced therapies for heart failure. Among the insured, decisions are complicated by level of deductibles and adequacy of insurance type in covering the transplant evaluation, operation, immunosuppression medications, and follow-up care. Although the Patient Protection and Affordable Care Act prohibits limiting coverage for pre-existing conditions (3), not all insurance carriers cover heart transplantation. Should all U.S. residents have equal access to health care insurance that covers heart transplantation?
In this issue of JACC: Heart Failure, DeFilippis et al. (4) used the Organ Procurement and Data Network to examine national trends in insurance payer mix for adult heart transplant recipients younger than age 65. This is an important focus because >80% of adult heart transplant recipients are younger than age 65 at the time of listing (4). A significant trend was observed in the proportion of adult heart transplant recipients covered by public insurance from 1997 through 2017. The proportion of Medicaid and Medicare payers increased >1.5-fold among heart transplant recipients younger than age 65 years. Over the past 2 decades, public insurance coverage for heart transplantation rose from less than one-third to approximately one-half. Consequently, the proportion of heart transplant recipients with private insurance decreased significantly. Among this younger cohort, Medicare was the primary public insurer, related to disability from heart failure. Medicare coverage increased across all strata of sex and race. Medicaid coverage increased in men, whites, and other non-African American groups, but was unchanged in women and decreased in African American patients. Similar findings were demonstrated among patients wait-listed for heart transplantation. Secondary insurance trends were not studied. Trends in self-pay were aggregated in the other/unknown category, which remained <10%, decreasing throughout the 2 decades of study.
Should One Size Fit All?
Public insurance may soon become the primary payer for heart transplantation in the United States. Increasing access to public insurance may contribute to equitable receipt of advanced heart failure therapies, particularly among underserved populations. Previous works have demonstrated significant increases in heart transplant listings among African Americans living in states that approved the Affordable Care Act Medicaid Expansion (5); however, as demonstrated in the DeFilippis et al. (4) study, increases in Medicaid coverage for heart transplantation have not been uniform across race or sex in the United States. Standardization of public insurance benefits is needed.
Society must determine whether the value of heart transplantation is worth the cost of expanding public insurance. More than 2,000 heart transplants are performed annually in adults younger than age 65 years, which is limited by donor availability (4). Heart transplantations are estimated to cost $97,000 per quality-adjusted life year, which is $57,000 above the cost for quality-adjusted life year of end-stage heart failure patients requiring inotropes (6). Median survival after heart transplantation is >10 years and allows individuals to meaningfully contribute back to society. Compared with private insurance, public insurance has been associated with reductions in survival, but is hypothesized to be secondary to fixable issues such as limited coverage or high deductibles for immunosuppression medications and specialty care (7).
Obstacles exist in public insurance. Multiple parts of Medicare are needed to cover heart transplantation at most centers: Part A hospital insurance, Part B medical insurance, and Part D prescription coverage. Part C, Medicare Advantage, may also be accepted for heart transplantation; Part C is supported through a private insurer and, at a minimum, includes coverage similar to Parts A and B and sometimes D. Patients with Parts A and B only can expect to pay up to 20% of medical charges plus other previously designated Part B deductibles as well as the high cost of immunosuppression medications (8). Depending on the wealth of the patient, this may make heart transplantation unattainable.
Medicaid coverage for heart transplantation varies by state and provider. As of September 2018, the majority of states have adopted the Affordable Care Act Medicaid Expansion, but many states with higher density racial/ethnic minority populations have not. The future of this policy is in flux. In addition, known biases exist toward patients who have Medicaid (9). Some specialists refuse to see patients with Medicaid as a sole payer. This may put patients at a disadvantage for receiving heart transplantations.
Barriers to public insurance can be overcome. Public insurance coverage has evolved since the initial passage of Medicare and Medicaid laws in 1965. In the last couple decades, bipartisan support has expanded public insurance to vulnerable populations and the general public. The 2018 mid-term polls suggested that bipartisan support continues for public insurance. Reducing public insurance barriers may require a single public payer that provides compensation equitable to what private insurers receive, limits total deductibles to a fair percentage based on income, and is standardized across the United States with accessibility to all U.S. residents. Inequities in receiving heart transplantations may persist because factors expand beyond insurance, but insurance has a prominent role. With the elections done, remember that patient advocacy and a political voice are powerful ways of influencing health care policy. The evolution of U.S. health care policy is not complete: Unus pro omnibus, omnes pro uno (One for all and all for one).
↵∗ Editorials published in JACC: Heart Failure reflect the views of the authors and do not necessarily represent the views of JACC: Heart Failure or the American College of Cardiology.
Dr. Breathett has received support from National Heart, Lung, and Blood Institute grant K01HL142848, University of Arizona Health Sciences, Strategic Priorities Faculty Initiative Grant, and University of Arizona, Sarver Heart Center, Women of Color Heart Health Education Committee Grant.
- 2019 American College of Cardiology Foundation
- Henry J.,
- Kaiser Family Foundation
- Rangel C.B.
- DeFilippis E.M.,
- Vaduganathan M.,
- Machado S.,
- Stehlik J.,
- Mehra M.R.
- Breathett K.,
- Allen L.A.,
- Helmkamp L.,
- et al.
- Long E.F.,
- Swain G.W.,
- Mangi A.A.
- Tumin D.,
- Foraker R.E.,
- Smith S.,
- Tobias J.D.,
- Don Hayes J.
- ↵Medicare. Your Medicare coverage. Transplants (adults). Available at: https://www.medicare.gov/coverage/transplants. Accessed October 26, 2018.
- Niess M.,
- Blair I.,
- Furniss A.,
- Davidson A.