paying medical bills. This probably reflects the fact that people with chronic conditions are more likely to have persistently high financial burdens, and that contributes to higher accumulated levels of medical debt that stay around for more than just a year.

There would clearly be a lot of practical issues with implementation. Should all chronic conditions be used, or just a select group? Also, some people with chronic conditions are more likely to choose expensive plans that have higher premiums, in order to cover their expenses. Some measure of affordability needs to be incorporated in data collection. It is important, at least from the standpoint of testing different affordability thresholds, to get some real-world experience from people about whether they find certain levels of out-of-pocket spending to be affordable or not.


Gary Claxton (Kaiser Family Foundation) focused mostly on employer-sponsored health insurance and some on nongroup health insurance, where the out-of-pocket expense risks are and how that has changed or not changed over time. He explained that most of the information is from a survey conducted at the Kaiser Family Foundation with the Health Research and Education Trust, but also some data from MEPS, looking at group and nongroup out-of-pocket shares.

Health Insurance Characteristics

He opened his presentation with two observations about what we know and don’t know about health insurance, and its adequacy, and our ability to characterize whether or not someone has good health insurance, and what that means to out-of-pocket risk.

His first point was that there is a lot that is not known about how good health insurance is. Surveys can provide information about deductibles and out-of-pocket maximums, but they cannot keep people long enough on the phone to ask about limits on rehabilitation services, and whether or not biological drugs are covered at certain levels, whether or not they are part of the out-of-pocket maximum, or all the other things that lead to high exposure to out-of-pocket risk, even when people have what they think is good health insurance.

His second point is that the kind of insurance is as important as any trends in terms of out-of-pocket risks. Small-group health insurance plans are different from large-group plans, and they are both different from nongroup health insurance in terms of out-of-pocket burdens and protections.

The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement