Out-of-Pocket Financial Burden for Low-Income Families with Children: Socioeconomic Disparities and Effects of Insurance Alison A. Galbraith, MD Sabrina T. Wong, RN, PhD Sue E. Kim, PhD, MPH Paul W. Newacheck, DrPH

Background Socioeconomic disparities exist in health care access, use, and outcomes Limited data on disparities in financial burden of out-of-pocket (OOP) health care expenditures Financial burden may prevent seeking needed care, especially with low-income

Background Family perspective important when examining financial burden –Catastrophic expenses for one family member can impact whole family –Insurance status may differ among family members Effect of insurance on financial burden for families with children unclear

Objectives To determine whether socioeconomic disparities exist in financial burden of OOP health care expenditures for families with children To determine whether health insurance coverage decreases financial burden for low-income families

Methods Design: Cross-sectional family-level analysis Dataset: 2001 Medical Expenditure Panel Survey (MEPS) Subjects: Families with a child <18 –defined as two or more persons living together in the same household related by blood or marriage

Primary Outcome Variable OOP financial burden: proportion of family income spent on OOP health care expenditures for all family members –71 families with incomes < $1,000 excluded Total OOP expenditures Family income

OOP Health Care Expenditures Sub-divided into expenditures for: –Health services –Health insurance premiums 188 families with missing premium data excluded

Primary Predictor Variables Family income category (% FPL) Family insurance coverage –all members publicly insured all year –all members privately insured all year –mix of public and private with no uninsured periods –partial coverage –all members uninsured all year

Analysis Financial burden computed by averaging financial burden experienced by individual families t test used to compare mean financial burden between lowest and highest income groups All data weighted and adjusted to account for complex survey design

Analysis Multivariate linear regression to assess association between insurance and financial burden –Limited to low-income families (< 200% FPL) –Controlled for: family size, race/ethnicity, education, region, MSA, health status, and presence of limitations

Analysis Separate regressions for financial burden with and without premiums Data log-transformed for regression, then back-transformed for ease of interpretation

Results Sample size: 4,531 families with children Mean OOP health care expenditures per family: $1,153 health care services $1,505 premiums $2,658

Results Mean family OOP financial burden: $29 per $1,000 health care services $31 per $1,000 premiums $60 per $1,000 of family income

Mean OOP Expenditures per $1,000 Income

OOP Financial Burden for Low-Income Families Family Insurance excluding premiums including premiums Public Private Public + Private Partial coverage Uninsured -17.3% 105%* 70.9% 46.2% ref -2.2% 758%* 353%* 129%* ref Controlling for family size, race/ethnicity, education, region, MSA, health status, and limitation of activity % Difference in OOP Financial Burden * p < 0.05

Health care use for publicly insured and uninsured low-income families Higher mean number of physician visits per family member for publicly insured (3.6 vs. 0.6; p < 0.001) Publicly insured less likely to have family member forgo needed care because family needed money for food, clothing, housing (5% vs. 22%; p<0.01)

Limitations Premium data missing on 4% of families Analysis does not account for complexity of heterogeneously insured families Measure of financial burden subject to outliers

Conclusions Socioeconomic disparities exist in financial burden of OOP health care expenditures for families with children For low-income families, full-year public coverage provides greater protection from financial burden than full-year private coverage

Conclusions While public coverage not associated with decreased financial burden for low-income families compared to uninsured, it allows for increased use and less forgone care

Implications Low-income families may benefit from extending public insurance to family members of eligible children Caution should be exercised with policies to move low-income uninsured into private insurance

Acknowledgements Agency for Healthcare Research and Quality