Life Disruptions for Midlife and Older Adults With High Out-of-Pocket Health Expenditures

This study does a good job of pointing out how high out-of-pocket health expenditures can cause serious and significant problems in peoples' lives. It can place great financial burdens on families who, because of these health expenditures, may have difficulty paying their household bills or affording basic living expenses. These financial impacts on the lives of patients, who actually have health insurance, are rarely considered by health care providers when making health care recommendations.

Underinsurance has often been defined by using financial criteria, such as those who spend more than 10% of their income on health care, or 5% for those below 200% of the federal poverty level are considered to be underinsured (1,2,3,). Using this definition, national estimates of underinsurance has been reported in the 7% to 12% range (3,4). We conducted a study on Underinsurance in Colorado using an experiential definition which was based on patients' reporting of not obtaining recommended care because they could not afford it, in spite of having health insurance (5). Our study administered a survey to 37 primary care practices, where patients responded to a series of questions, determining if in the preceding 12 months they were unable to receive recommended care, fill a recommended prescription, or obtain recommended tests because of trouble paying for them. To qualify as having underinsurance they had to be insured during this full 12 months. Those who responded that they did not receive or obtain recommended care because of being unable to afford or pay for it, in spite of having insurance, were labeled as underinsured. Of those with insurance for a full year, 36.3% were underinsured, and out of those 50.2% felt that their health suffered because they could not afford recommended care, a rate that was similar to those who were uninsured. This study included Medicare patients, who had similar findings.

It is valuable to have a study look beyond the ability to afford recommended health care, and research the impact these expenditures can have on the patients' personal lives. As the cost of health care rises, one way to try to keep premiums more affordable has been to cost-shift greater amounts of personal medical financial responsibility to the individual. This has had a major impact on family budgets, where more and more sacrifices have to be made affecting patients' lives and their health. If physicians work under the assumption that the care they provide to their patient is to improve their lives and their health, it is important to be aware of the ramifications and impact that cost sharing has created for our patients. Patients may not bring up these topics to their doctor, but many, even though they may have health insurance, may still not be able to afford the recommended care. If they do obtain the recommended care, their personal financial responsibility may exceed their ability to pay. They then may have to make tradeoffs in other areas of their lives which can have major impacts on their health, household budgets, and their quality of life. This topic is worthy of conversation and consideration in provider-patient interactions.

REFERENCES

1. Bashshur R, Smith DG, Stiles RA. Defining underinsurance: a conceptual framework for policy and empirical analysis. Med Care Rev. 1993;50:199-218.
2. Schoen C, Doty MM, Collins SR, Holmgren AL. Insured but not protected: how many adults are underinsured? Health Aff (Millwood). 2005;Suppl Web Exclusives:W5-289-W5-302.
3. Ziller EC, Coburn AF, Yousefian AE. Out-of-pocket health spending and the rural underinsured. Health Aff (Millwood). 2006;25:1688-99.
4. State-specific prevalence estimates of uninsured and underinsured persons--Behavioral Risk Factor Surveillance System, 1995. MMWR Morb Mortal Wkly Rep. 1998;47:51-5.
5. Voorhees, K, Fernald, D, et.al. Underinsurance in Primary Care: A Report from the state Networks of Colorado Ambulatory Practices and Partners (SNOCAP). J Am Board Fam Med 2008;21:309-316.

Competing interests:   None declared