a combination of low income and poor coverage. New England and the Midwest saw slightly lower rates.

She cautioned, however, that it is important to keep in mind in looking at these rankings that some of these levels are separated by 1 percentage point differences. In all states, families with lower income are most at risk due to higher rates of uninsured and also less protective coverage.

To summarize, 17 percent of families, about 44 million people, had high out-of-pocket costs in 2009 relative to their income. Most at risk were low-income households; nearly 40 percent of insured families under 200 percent of the federal poverty level had high out-of-pocket costs.

High out-of-pocket costs varied dramatically by state, ranging from 12 to 24 percent of families.

Collins observed that the ACA reforms beginning in 2014, with Medicaid expansion, premium tax credits, and lower cost sharingfor qualified health plans in the exchanges, the essential benefit package, and market reforms, should lead to a dramatic reduction in the share of families with high out-of-pocket costs as a share of their income both nationally and across states. But risks include ongoing risks of rapid health care cost growth compared with income, families with chronic illness, the design of benefit plans and the state implementation of the exchanges, enrollment coordination between coverage options, the pace of implementation, and the exemptions of health plans from the law. She concluded by saying that all of this suggests a need to monitor the law over time, at the state and national levels.


Peter Cunningham (Center for Studying Health Systems Change) presented findings related to trends in out-of-pocket spending and high financial burden, how they have changed over time, how they differ for different population groups, and what they imply for affordability thresholds. When one thinks about affordability thresholds for medical care, the question is whether they should be different for people with chronic conditions or people with health conditions that require high expenditures. Clearly, people with health problems use more health care, and they spend a lot more on health care than people with fewer or no health problems. But does that necessarily mean that they should have a different affordability threshold?

For example, if it is determined that health care should be affordable up to, say, 5 percent of a family’s income, is there a reason why that should be different for people with chronic conditions? It could simply mean that people with chronic conditions are going to meet that threshold more often. To make the case that there should be a different threshold for people with

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