spending risk, or thresholds, as families that spent 10 percent or more of their income annually on medical needs, or people who spent 5 percent of their income, if their incomes were under 200 percent of poverty. The results show the percentage of families and total counts of people in families with high medical care expenses compared with their income.

Tilipman and Sampat, in their analysis of the 2010 CPS for the Commonwealth Fund, examined two threshold measures of out-of-pocket spending and premiums: 10 percent or more of income and 5 percent or more if income was under 200 percent of poverty.1 They found that, among all families at the 10 percent or more threshold, 13 percent of families spent 10 percent or more of their income on out-of-pocket expenses. If the 5 percent threshold is added, that jumped up to 17 percent. Among insured families, 11 percent of families spent 10 percent or more of their income on out-of-pocket costs. The percentage increases to 15 percent of families if the 5 percent threshold is added. Among uninsured families, the risks were clearly the highest, with nearly a quarter of these families experiencing high out-of-pocket spending relative to their low incomes, using the combined 10 percent and 5 percent threshold—a big jump when the lower threshold is added.

Families most at risk were those with low incomes, Collins said. Nearly 40 percent of families under 133 percent of poverty had high out-of-pocket costs, and 31 percent of those with incomes between 133 and 199 percent of poverty also had high out-of-pocket spending relative to their incomes.

When they looked at just insured families, 37 percent of those with incomes under 133 percent of the poverty level and nearly 40 percent of those with incomes under 133-139 percent of the poverty level had high out-of-pocket medical care costs and premiums. It shows a combination of low income and also poor coverage options at that income level, less employer coverage among low-income groups, and people in employer plans with high cost-sharing relative to lower paying jobs.

Collins observed that a big advantage of the 2010 data is being able to look at differences across states in medical care cost spending. Families in the Southeastern states were most at risk of spending large amounts of their income on out-of-pocket health care costs, amounting to nearly a quarter of the population in those states spending 10 or 15 percent of their income on out-of-pocket medical care costs. Some of the highest spending states were Alabama, Arizona, Arkansas, Indiana, Kentucky, Mississippi, and Tennessee. Focusing just on insured families, Mississippi and Arkansas had had the highest rates of high out-of-pocket spending, again reflecting

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1 Analysis of the 2010 Current Population Survey, U.S. Census Bureau, by Nicholas Tilipman and Bhaven Sampat of Columbia University for The Commonwealth Fund.



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