additional income in budgets to pay for both health insurance and out-of-pocket costs.

They used the family economic self-sufficiency standard, which considers such necessities as child care, food, housing, taxes, transportation, and miscellaneous costs, which are defined as 10 percent of other costs. They found risks in the analysis: people with high spending in any given year, such as people with chronic health problems or catastrophic accidents, 25 percent of those with incomes between 200 and 250 percent of poverty would not have had room in their budgets for the premiums and the out-of-pocket costs.

As income rises past 200 percent of poverty, cost exposure also rises. Premium cost-sharing increases from 6.3 to 8.5 percent of income as income moves from 200 percent of poverty to 250 percent of poverty.

Gruber and Perry also found differences by states. Higher shares of people in states with higher cost of living would not have had room in their budgets for premiums and out-of-pocket costs. This is exacerbated for people living in states with a high cost of living who also had high health care spending: more than 30 percent of people in this group with incomes between 200 and 250 percent of poverty did not have room in their budgets for premiums and out-of pocket costs. The March 2010 Current Population Survey (CPS) asked about total out-of-pocket expenditures, including premiums, and enabled estimates of risk at the state level, an exciting development in terms of tracking and understanding what has been going on across states. The CPS asks about total out-of-pocket costs for medical care services in 2009, including premiums and costs reimbursed by insurance. For households with more than one member, the data files aggregate spending for each family member in total family expense. Preliminary estimates based on one year of data in 2010 indicate significant variation in the percentage of families with high out-of-pocket spending across states. Tracking trends in out-of-pocket costs nationally and by state for those insured, uninsured, and by poverty status will help inform reform implementation and future policies.

Collins briefly explained the data and method used in the analysis she conducted with Bhaven Sampat, Cathy Schoen, and Nicholas Tilipman, from Columbia University. They used the new out-of-pocket spending measure in the 2010 CPS to analyze out-of-pocket cost burden at the household/family level, also using a measure of family income. The CPS asks about total out-of-pocket costs for medical services in 2009, including premiums and costs reimbursed by insurance. For households with more than one member, the data files aggregate spending for each family member in total family expense. They classified a household as insured if all members in the family are insured. Uninsured families are families in which everyone is uninsured or some members are uninsured. They defined out-of-pocket



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