because of costs or who are potentially at financial risk if they should have an illness or injury and be unable to postpone care. Indeed, research studies regularly find that the uninsured with low incomes spend a high share of their income on health care although they also report going without recommended care because they cannot afford it. That said, the panel thinks that modeling risk prospectively should be separate from metrics that measure actual spending retrospectively. Projecting medical economic risk should take into account insurance coverage, health status, and income to predict the population at risk of potentially unaffordable costs (see Chapter 4).

The strong advantage of the SPM and annual counts of poverty rates is that all of the estimates are based on what happened as reported in household surveys—rather than estimates of what might have happened. To the extent that policies succeed in enrolling the uninsured into plans that provide affordable insurance with low or no premiums for those who are below or near poverty, with insurance choices that enhance access with protection against out-of-pocket medical care bills, the economic burden approach currently used by the Census Bureau should find a reduction in the number of people who are impoverished by out-of-pocket medical care costs as well as a drop in the number of uninsured. Similarly, for those with insurance, if policy reforms result in benefit standards that improve protection and new premium subsidies that lower premium costs, the medical economic burden approach that the Census Bureau is currently using should indicate a reduction in the number of insured families with low incomes that have high out-of-pocket medical care costs for medical care. If, however, policy reforms fail to limit premiums or out-of-pocket costs relative to income, the current medical burden approach of the SPM would indicate either no improvement or more people impoverished due to medical spending. To inform policy, it will be important for the Census Bureau’s SPM data to reflect trends in actual spending—not hypothetical spending. Therefore, there should be no adjustment for underutilization of medical care by the uninsured in the SPM estimates of medical care economic burden.

Recommendation 2-4: The panel recommends that the U.S. Census Bureau continue to use a definition of resources for the Supplemental Poverty Measure and estimates of medical care economic burden that incorporates estimates of actual out-of-pocket spending on health insurance premiums and other out-of-pocket expenses for medical care. The Census Bureau should not model potential spending for people lacking health insurance coverage.

Contrary to the Interagency Technical Working Group’s suggestion that the Census Bureau explore an adjustment for potential underuse of medical care for the uninsured, we recommend that the Census Bureau continue



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