ditures for other necessities. An estimated 90 percent or more of households with incomes up to 400 percent of poverty will be able to afford the costs of necessities, premiums, and average out-of-pocket costs for medical care based on current consumption patterns. However, their analysis indicates that, in the 200 to 300 percent of poverty range, those with health care needs that put them in the top 10 percent of the spending distribution could face unaffordable costs.

As the ACA insurance provisions are implemented, it will be important to have a measure of the economic burden of medical care costs (premiums and out-of-pocket spending) that assesses whether the reforms lower the burden for those with incomes near or below poverty and moderate the risk of expenditures that are high relative to incomes in the targeted poverty ranges. It will also be important to assess whether the source of high economic burdens comes from required premium payments, indicating that premium subsidies are inadequate, or from out-of-pocket medical care expenses, pointing to potential gaps in insurance benefit design. Such assessments are possible with data collected by the Census Bureau for purposes of the SPM.

The new law also relies on states to set up insurance exchanges, provide choices of plans that will be eligible for premium tax credits, and expand Medicaid. States vary in their enthusiasm and commitment to implement the legislation. Based on Medicaid’s historic experiences, states also vary in how easy or difficult they make it to enroll. Thus, the extent to which new provisions for premium assistance and limits on out-of-pocket exposure for medical care succeed in lowering burden and risks for poor, low-income, and middle-income families may vary substantially across states.

Currently available data enable a cross-sectional perspective on medical care economic burden using essentially a 1-year time horizon for income and medical-related expenses. To the extent that individuals or families incur expenses in 1 year that result in debt they are paying off over time, measures related to current-year spending will capture at best the amount paid off in the current year and any new medical expenses. The measures will be unable to assess whether some households incur high expenses year after year. Because of this limit it would be useful to continue to build on the Supplemental Poverty Measure to assess and track how medical care economic burden changes over time.

RECOMMENDATIONS FOR MEASURING MEDICAL CARE ECONOMIC BURDEN

Providing Additional Information in Census Bureau SPM Reports

In the context of new national medical care policy that makes a commitment to affordability with explicit standards and thresholds, the im-



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