New heart failure data suggest some healthcare disparities are getting worse as time goes on
A deep dive into a recent Heart Failure Society of America (HFSA) report makes it clear that heart failure (HF) outcomes can still be significantly influenced by where a person lives or how much money they earn. That report, the HFSA Heart Failure Clinic Database Annual Report, includes data from more than 300 U.S. clinics. And it says a lot about the modern healthcare landscape in the United States.
Cardiology health policy experts Nicholas Chiu, MD, MPH, and Rishi K. Wadhera, MD, believe the report should be a wake-up call for healthcare policy reform. They made their case in a new editorial published in the Journal of Cardiac Failure Intersections.[1].
Wadhera is the associate director of the Richard A. and Susan F. Smith Center for Outcomes Research at Beth Israel Deaconess Medical Center in Boston. Chiu is a cardiology fellow with Harvard Medical School and Mass General Brigham/Brigham and Women’s Hospital.
The two co-authors said these stats provide a map of the policy choices that resulted in poor outcomes. At the same time, the numbers show how much room there is for improvement.
For example, the U.S. is one of the wealthiest nations in the world, but it has greater income inequality than most other high-income countries. In addition, the gap in health outcomes between the richest and poorest Americans is widening over time.
"Poverty is one of the most powerful and persistent determinants of health in the United States," the authors wrote. "Patients with heart failure are especially vulnerable to the downstream effects of poverty, because effective care requires costly medications, frequent monitoring, and reliable access to specialty care. Despite a decade of therapeutic advances, poverty continues to shape who develops HF, who can access high-quality care, and how patients live with the disease."
They pointed to glaring inequities in the stats, where rural America is seeing increasingly worse HF outcomes. Age-adjusted HF mortality increases faster in rural communities than in urban areas. This can be linked to the fact that rural patients are receiving fewer cardiology visits after hospital discharge and are less likely to achieve optimal guideline-directed medical therapy.
At the same time, the HFSA report shows that age-standardized rural HF hospitalizations decreased by nearly 30% between 2010 and 2022. While this may appear to be a good thing on the surface, the paradox of higher mortality tells a different story.
"Decreasing admissions alongside worsening outcomes do not signal healthier patients, they signal a healthcare infrastructure eroding around them," the authors wrote. "As rural hospital closures intensify and clinical workforces thin in these communities, fewer hospitalizations may reflect a lost opportunity to be admitted for needed care rather than a reduced need for care."
The two co-authors also noted that poverty and HF are not necessarily spread evenly across the country, but they converge clearly in numerous ways. The South consistently accounts for more than 40% of all primary HF hospitalizations nationally, and Mississippi, Oklahoma, Alabama, and Arkansas repeatedly rank among the worst states for age-adjusted HF mortality.
"The concentration is not coincidental, and geography itself is not the cause," the authors argued. "Place is a proxy for the determinants of HF outcomes: the economic resources patients require to manage a chronic illness, the health system built around them to treat it, and the policy environment that shapes both, varying from one state to the next."
Changes in federal healthcare policy may worsen poor rural HF outcomes
The authors noted there have been some positive policy changes in recent years. The 2014 Medicaid expansion under the Affordable Care Act was associated with substantial reductions in uninsured hospitalizations among lower-income HF patients and a reduction in cardiovascular mortality. The more recent Inflation Reduction Act in 2022 was designed to improve prescription drug affordability for Medicare beneficiaries. The early evidence suggests that policy is improving patient medication adherence.
However, recent federal policy changes might produce setbacks and reverse these gains. The One Big Beautiful Bill Act (HR 1), signed into law in July 2025, moved in the opposite direction of the Affordable Care Act and Inflation Reduction Act. The authors said it enacted roughly $1 trillion in federal health program cuts over the coming decade. Starting January 2027, Medicaid work requirements will require nondisabled adults to work at least 80 hours per month to maintain coverage.
According to the authors, HR 1 is likely to leave millions without insurance coverage. And the increase in Medicaid-covered HF hospitalizations reported in the HFSA report is exactly what makes these cuts so consequential. Cutting off access to ambulatory care can expose patients to catastrophic costs when hospitalized, for instance, and rural hospitals are left holding the bill when patients cannot pay.
Additionally, the authors said the HFSA report points to an increasingly fragile rural health care infrastructure. Some estimates say federal Medicaid spending in rural areas will decline by roughly $137 billion over the next decade.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: [email protected]