Stroke in the uninsured.

See related article, pages 2149 –2156. I n its landmark publication, " Crossing the Quality Chasm, " published in 2001, the Institute of Medicine defined 6 fundamental dimensions of quality in health care, one of which is equity. 1 Whereas dimensions such as evidence-based methods and safety are subjects of intense research, equity has until recently been less in focus. Much of the healthcare inequities in low-and middle-income countries are related to insurance status. In the 2 biggest countries in the world, out-of-pocket payments as a portion of total healthcare spending are very high: 50% to 60% in China and approximately 80% in India. 2,3 An inevitable consequence is that a serious and costly disease like stroke very often has disastrous financial consequences for the patient and his or her family, particularly when combined with loss of household income. In this issue of Stroke, an important article by Heeley et al reports on how frequent economic disasters after stroke are in China. 4 The authors show that as many as 71% of all patients with stroke in urban China may experience catastrophic healthcare costs, defined as Ն30% of annual income. More than one third of the patients who are above the poverty line before stroke (set at a very modest income of $1 to $2 US per day) fall below it after stroke. With 1.5 to 2 million strokes occurring annually in China 5 and from the information provided in the article, it can be estimated that stroke makes at least half a million Chinese people fall below the poverty line each year. Because the study was performed in urban settings, the actual number is probably higher considering that poverty is more prevalent and insurance coverage lower in rural China. 6 These numbers are compared with an estimated 76 000 stroke survivors in the United States being unable to pay for their medications, 7 even a high number. The study by Heeley et al highlights the importance of health insurance in countries where not all citizens are covered by public health insurance. 4 If stroke occurs during working years, people without health insurance are nearly 7 times more likely to experience catastrophic costs than workers with health insurance. This is in accordance with the very idea of insurance. At the same time, it is a sinister illustration of health inequities in the many low-and middle-income countries where health insurance coverage …