Trends in health care financial burdens, 2001 to 2009

Milbank Q. 2014 Mar;92(1):88-113. doi: 10.1111/1468-0009.12042.


Context: Over the past decade, health care spending increased faster than GDP and income, and decreasing affordability is cited as contributing to personal bankruptcies and as a reason that some of the nonelderly population is uninsured. We examined the trends in health care affordability over the past decade, measuring the financial burdens associated with health insurance premiums and out-of-pocket costs and highlighting implications of the Affordable Care Act for the future financial burdens of particular populations.

Methods: We used cross sections of the Medical Expenditure Panel Survey Household Component (MEPS-HC) from 2001 to 2009. We defined financial burden at the health insurance unit (HIU) level and calculated it as the ratio of expenditures on health care-employer-sponsored insurance coverage (ESI) and private nongroup premiums and out-of-pocket payments-to modified adjusted gross income.

Findings: The median health care financial burden grew on average by 2.7% annually and by 21.9% over the period. Using a range of definitions, the fraction of households facing high financial burdens increased significantly. For example, the share of HIUs with health care expenses exceeding 10% of income increased from 35.9% to 44.8%, a 24.8% relative increase. The share of the population in HIUs with health care financial burdens between 2% and 10% fell, and the share with burdens between 10% and 44% rose.

Conclusions: We found a clear trend over the past decade toward an increasing share of household income devoted to health care. The ACA will affect health care spending for subgroups of the population differently. Several groups' burdens will likely decrease, including those becoming eligible for Medicaid or subsidized private insurance and those with expensive medical conditions. Those newly obtaining coverage might increase their health spending relative to income, but they will gain access to care and the ability to spread their expenditures over time, both of which have demonstrable economic value.

Keywords: Affordable Care Act; affordability; health insurance.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Child
  • Child, Preschool
  • Cost of Illness
  • Cross-Sectional Studies
  • Delivery of Health Care / economics*
  • Female
  • Financing, Personal / statistics & numerical data
  • Financing, Personal / trends*
  • Health Expenditures / statistics & numerical data
  • Health Expenditures / trends*
  • Humans
  • Infant
  • Infant, Newborn
  • Insurance, Health / economics*
  • Male
  • Medicare / statistics & numerical data*
  • Middle Aged
  • Patient Protection and Affordable Care Act / economics*
  • United States
  • Young Adult