Alison A. Galbraith, MD Sabrina T. Wong, RN, PhD Sue E. Kim, PhD, MPH Paul W. Newacheck, DrPH

1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

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

8. 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

9. 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

10. 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

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

12. 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

13. 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

14. Mean OOP Expenditures per $1,000 Income

15. Mean OOP Expenditures per $1,000 Income

16. OOP Financial Burden for Low-Income Families % Difference in OOP Financial Burden Controlling for family size, race/ethnicity, education, region, MSA, health status, and limitation of activity * p < 0.05

17. 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)

18. 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

19. 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

20. 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

21. 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

22. Acknowledgements • Agency for Healthcare Research and Quality