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
Total OOP expenditures
Family income
– 71 families with incomes < $1,000 excluded
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:
$2,658
$1,153
health care services
$1,505
premiums
Results
• Mean family OOP financial burden:
$60 per $1,000 of
family income
$29 per $1,000
health care services
$31 per $1,000
premiums
Mean OOP Expenditures per $1,000 Income
$140
premiums
$120
health services
$100
$80
$60
$40
$20
$0
<100% FPL
100-199% FPL
200-400% FPL
>400% FPL
Mean OOP Expenditures per $1,000 Income
$140
premiums
$120
health services
$100
$80
$60
$40
$20
$0
<100% FPL
100-199% FPL
200-400% FPL
>400% FPL
OOP Financial Burden for
Low-Income Families
% Difference in OOP
Financial Burden
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
* 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