portant roles that states will play going forward, and policy differences by age, the panel recommends three actions for consideration in future Census Bureau publications to show the extent of medical care economic burden in relation to the SPM. All three recommendations assume continuation of the current treatment of medical care out-of-pocket expenses in the SPM resource definition—that is, subtracting medical spending from net income adjusted for taxes, in-kind transfers, child support payments, and work-related expenses.
Recommendation 2-1: The panel recommends that the U.S. Census Bureau refine its Supplemental Poverty Measure (SPM) reports and tables to include the estimated effects of medical care economic burden on poverty by component, showing the effects of premiums separately from other out-of-pocket expenses. It further recommends that the SPM reports and tables include the estimated effects of medical care economic burden by region or state, recognizing that aggregation over time or by groups of states may be necessary to obtain reliable estimates.
By this recommendation the panel supports not only showing the effects on SPM poverty estimates of the composite measure of out-of-pocket medical care spending, as is currently done, but also showing separately the effects of spending on out-of-pocket premiums and medical care costs to assess the impact of each on the SPM estimates. The panel also urges that Census Bureau SPM reports provide not only national estimates, but also estimates at the state or regional level to assess how medical care economic burden varies geographically. If state samples are not sufficient for single-year estimates, the Census Bureau should consider combining years or combining estimates for specific geographic areas that include several states, or both.
Reporting such data annually will provide an absolute measure of the number of people who become poor as a result of medical costs, the extent to which it is premiums or other spending on medical care or both that move people into poverty, and the extent to which medical care economic burden varies depending on where individuals and families live. This information will be important to efforts to track changes as Medicaid expansions and other insurance reforms unfold. It will also provide information during recessions regarding whether insurance reforms are able to protect families when their incomes fall.
Recommendation 2-2: The panel recommends that the U.S. Census Bureau examine medical care economic burden in its Supplemental Poverty Measure (SPM) reports and tables by providing estimates of the number of people who move from higher to lower multiples of the