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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