Out-of-Pocket Financial Burden for Low-Income Families with Children:

Socioeconomic Disparities and Effects of Insurance

Alison A. Galbraith, MDSabrina T. Wong, RN, PhD

Sue E. Kim, PhD, MPHPaul W. Newacheck, DrPH

Background

• Socioeconomic disparities exist in health care access, use, and outcomes

• Limited data on disparities in financial burden of out-of-pocket (OOP) health care expenditures

• Financial burden may prevent seeking needed care, especially with low-income

Background

• Family perspective important when examining financial burden– Catastrophic expenses for one family member

can impact whole family– Insurance status may differ among family

members

• Effect of insurance on financial burden for families with children unclear

Objectives

• To determine whether socioeconomic disparities exist in financial burden of OOP health care expenditures for families with children

• To determine whether health insurance coverage decreases financial burden for low-income families

Methods

• Design: Cross-sectional family-level analysis

• Dataset: 2001 Medical Expenditure Panel Survey (MEPS)

• Subjects: Families with a child <18– defined as two or more persons living

together in the same household related by blood or marriage

Primary Outcome Variable

• OOP financial burden: proportion of family income spent on OOP health care expenditures for all family members

– 71 families with incomes < $1,000 excluded

Total OOP expenditures

Family income

OOP Health Care Expenditures

• Sub-divided into expenditures for:– Health services– Health insurance premiums

• 188 families with missing premium data excluded

Primary Predictor Variables

• Family income category (% FPL)• Family insurance coverage

– all members publicly insured all year– all members privately insured all year– mix of public and private with no uninsured

periods– partial coverage– all members uninsured all year

Analysis

• Financial burden computed by averaging financial burden experienced by individual families

• t test used to compare mean financial burden between lowest and highest income groups

• All data weighted and adjusted to account for complex survey design

Analysis

• Multivariate linear regression to assess association between insurance and financial burden – Limited to low-income families (< 200% FPL)– Controlled for: family size, race/ethnicity,

education, region, MSA, health status, and presence of limitations

Analysis

• Separate regressions for financial burden with and without premiums

• Data log-transformed for regression, then back-transformed for ease of interpretation

Results

• Sample size: 4,531 families with children

• Mean OOP health care expenditures per family:

$1,153 health care services

$1,505 premiums

$2,658

Results

• Mean family OOP financial burden:

$29 per $1,000 health care services

$31 per $1,000 premiums

$60 per $1,000 of family income

$0

$20

$40

$60

$80

$100

$120

$140

<100% FPL 100-199% FPL 200-400% FPL >400% FPL

premiums

health services

Mean OOP Expenditures per $1,000 Income

$0

$20

$40

$60

$80

$100

$120

$140

<100% FPL 100-199% FPL 200-400% FPL >400% FPL

premiums

health services

Mean OOP Expenditures per $1,000 Income

OOP Financial Burden for Low-Income Families

Family Insuranceexcluding premiums

including premiums

PublicPrivatePublic + PrivatePartial coverageUninsured

-17.3%105%*70.9%46.2%

ref

-2.2%758%*353%*129%*

refControlling for family size, race/ethnicity, education, region, MSA, health status, and limitation of activity

% Difference in OOP Financial Burden

* p < 0.05

Health care use for publicly insured and uninsured low-income families

• Higher mean number of physician visits per family member for publicly insured (3.6 vs. 0.6; p < 0.001)

• Publicly insured less likely to have family member forgo needed care because family needed money for food, clothing, housing (5% vs. 22%; p<0.01)

Limitations

• Premium data missing on 4% of families

• Analysis does not account for complexity of heterogeneously insured families

• Measure of financial burden subject to outliers

Conclusions

• Socioeconomic disparities exist in financial burden of OOP health care expenditures for families with children

• For low-income families, full-year public coverage provides greater protection from financial burden than full-year private coverage

Conclusions

• While public coverage not associated with decreased financial burden for low-income families compared to uninsured, it allows for increased use and less forgone care

Implications

• Low-income families may benefit from extending public insurance to family members of eligible children

• Caution should be exercised with policies to move low-income uninsured into private insurance

Acknowledgements

• Agency for Healthcare Research and Quality