the same thing as the Supplemental Poverty Measure, and it does not seem to be the same as a measure of medical care economic risk.

Wilhelmine Miller (NORC at the University of Chicago) made a similar comment, stating that it seemed like the entire session addressed a range of factors that affect the likelihood of incurring high medical care economic risk, some of which are perhaps more appropriate for applying in a policy analytic sense, and others not. She said that although Ziliak treated them all as threshold issues, she was not sure, for example, that labor category is a threshold issue, even though job type has a lot to do with the ultimate risk of both expenses and debt. She wanted to hear from the presenters, who talked about everything from geographic variation to risk based on health condition, as to what is most salient.

Cunningham responded that although they were using different terminology, some of the issues are still the same in terms of what should be going into some kind of medical care risk index. For example, whether one uses chronic conditions or some other measure of people at risk for high spending, the issue is still the same. What the presenters are grappling with is whether there is something unique to people with chronic conditions or low-income people above and beyond what they spend or what their risk is for spending on an annual basis that should be considered.

In his talk, he said he pointed out that, for people with chronic conditions, their risk is not only for spending in any given year. It is also the risk for having the spending persist over a period of time, and that is qualitatively different from an annualized measure. He urged people not to get caught up in the differences in terminology, because the issues are still relevant to how should the index be computed, how one should do it, and whether there should be different considerations for different groups.

Garner questioned whether he was talking about a supplemental poverty threshold the way Ziliak was, when he said that people make spending decisions on health care based on their other spending needs. She said she thought that he is not just thinking about medical care economic risk, he is also saying that people have constraints in their household, which is exactly what the 1995 NRC report says and also what the Interagency Technical Working Group document says, that people make decisions interdependently. Medical expenditures are not independent from food, clothing, shelter, utilities, and the like. Or are they?

Garner continued the fact is that people with health insurance have greater flexibility when it comes to making those decisions. If they have health insurance, their decisions relative to food, clothing, shelter, and utilities are different than if they do not have health insurance. Cunningham responded that it is not an either/or situation; the distinction is between predictable and unexpected health care spending. With premiums, people are sharing the cost of health care with other people.



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