2018 State-level Estimates of Medical Out-of-Pocket Spending for Individuals with Employer-sponsored Insurance Coverage

March 2019:

U.S. health care spending continues to grow, reaching $3.6 trillion and 17.7% of the GDP in 2018.[i]  Unfortunately, a significant share of these costs are increasingly born by Americans in the form of increased deductibles, copayment, and coinsurance—commonly referred to as patient “out-of-pocket” (OOP) costs. Even for the 52% of Americans who have private health insurance through their own or their spouse’s employer, affordability of health care is a pressing issue. Nationally, the average deductible for families in 2018 was $3,392, and almost half (49.1%) of all Americans were enrolled in high-deductible health plans with a deductible of at least $2,700 for family coverage.[ii],[iii]

The State Health Access Data Assistance Center (SHADAC) at the University of Minnesota continues to monitor trends in coverage, access, and affordability. This brief highlights the affordability of coverage for those with employer-sponsored health insurance (ESI). Using data from the Annual Social and Economic Supplement (ASEC) of the 2019 Current Population Survey (CPS; data year 2018), we estimated family out-of-pocket costs for people with employer coverage across all 50 states and the District of Columbia (D.C.). For individuals with ESI, we looked at: (1) the family median out-of-pocket costs by state, and (2) an estimate of the high medical cost burden where family out-of-pocket spending is greater than 10% of household income. For additional estimates, please visit SHADAC’s State Health Compare web tool.

 

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[i] Centers for Medicare & Medicaid Services (CMS). (2019, December 5). NHE Fact Sheet. Retrieved from https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet/

[ii] State Health Access Data Assistance Center analysis of the 2018 American Community Survey microdata.

[iii] State Health Access Data Assistance Center, State-level Trends in Employer-Sponsored Health Insurance, 2014-2018. Available at: https://www.shadac.org/ESIReport2019

SHADAC Staff

p 612.624.4802
e shadac@umn.edu

Affordability and Access to Care in 2018: Examining Racial and Educational Inequities across the United States (Infographic)

The Centers for Medicare and Medicaid Services (CMS) recently reported that the cost of health care spending in the United States increased by 4.6 percent last year to reach an all-time high of approximately $3.6 trillion.¹ This report comes amidst a number of other concerning health care cost-related trends, such as the largest single-year increase for single-coverage premiums in 2018 from $6,368 to $6,715 (5.4 percent) for workers enrolled in employer-sponsored insurance (ESI) and an increase in average household spending on health care (out of pocket expenses, cost-sharing for ESI, and payroll taxes for Medicare, etc.) rising to a record $1.04 trillion.²

Rising expenses such as these have contributed to the record number of Americans (25 percent) who reported in 2019 that either themselves or a family member skipped or delayed needed medical care due to cost, according to the results from a new Gallup poll released earlier this month.³

This post examines Americans’ access and ability to afford medical care, focusing on inequities related to race/ethnicity and education, and using two recently updated measures from SHADAC’s State Health Compare: Adults Who Forgo Needed Medical Care and Adults with No Personal Doctor. These measures come from a SHADAC analysis of 2018 data from the CDC’s Behavioral Risk Factor Surveillance System (BRFSS).

  Racial and educational inequities persist in adults’ reported ability to afford needed medical care
Significant inequities in adults’ ability to afford medical care by race/ethnicity emerged when we examined the updated data for 2018. At the national level, our analysis showed that Hispanic/Latino adults were nearly twice as likely as White adults to forgo needed medical care due to cost (20.2 percent versus 10.5 percent), and African Americans/Black adults were 1.5 times as likely to report forgoing care compared to White adults (16.0 percent versus 10.5 percent). Hispanic/Latino adults were also significantly more likely to report forgoing medical care than White adults in 35 states and D.C., and this gap was greater than 20 percentage points in Maryland (31.4 percent versus 7.4 percent) and Missouri (34.4 percent versus 11.1 percent). Black adults were significantly more likely to report going without care than White adults in 24 states and D.C., and this gap was greater than 10 percentage points in four states: Iowa (16.2 percentage points), North Dakota (15.5 percentage points), Utah (11.5 percentage points), and Minnesota (10.2 percentage points).

Nationwide, Americans with less than a high school degree were almost three times as likely to report going without needed medical care due to cost as compared to those with a bachelor’s degree (21.1 percent versus 7.4 percent) in 2018. Adults with less than a high school education were significantly more likely to report forgone care due to cost compared to adults with college degrees in 2018 in all but two states—Montana and Vermont—and in the District of Columbia (D.C.). For four states this gap was greater than 20 percentage points in 2018—Georgia (21.1 percentage points), Maryland (20.9 percentage points), Oklahoma (21.2 percentage points), and Virginia (21.2 percentage points).*

  Racial/ethnic minorities and adults without a high school diploma less likely to have a personal doctor
Nationally, Hispanic/Latino and Black adults were both significantly more likely to report not having a regular doctor as compared to their White counterparts. Our analysis revealed that Hispanic/Latino adults were more than twice as likely as White adults to report not having a personal doctor (38.8 percent versus 18.4 percent), and Black adults were nearly 25 percent more likely to report not having a personal doctor compared with White adults (22.8 percent versus 18.4 percent).*

These inequities in access to care by race/ethnicity were present in a large majority of states. A significant gap between Hispanic/Latino and White adults with no personal doctor was present in 43 states, and Hispanic adults were more than three times as likely to report not having a personal doctor in five states (Connecticut, Maryland, Nebraska, New Jersey, and North Carolina). This significant gap also persisted between Black and White adults in 20 states, as we found that Black adults were more than twice as likely to not have a personal doctor in three states—Connecticut (22.8 percent versus 10.8 percent), Iowa (31.2 percent versus 15.1 percent), and Rhode Island (21.2 percent versus 9.9 percent).*

Nationally, adults with less than a high school degree were more than twice as likely to not have a regular doctor as those with an undergraduate degree or greater (32.4 percent versus 15.7 percent). This pattern was consistent across nearly the entire nation, as adults with less than a high school education were significantly more likely than college graduates to report not having a personal doctor in 46 states. The gap between less than high school graduates and college graduates was larger than 20 percentage points in eight states (California, Colorado, Georgia, Maryland, Nebraska, Nevada, New Jersey, and Utah).

Note
* Data were not available or were suppressed for some states because the number of sample cases was too small, so this number could be higher if data were available in all states. For education breakdowns, adults are defined as 25 years of age and above. For race/ethnicity breakdowns, adults are defined as 18 years of age and above. All differences are statistically significant at the 95% level.

Explore Additional BRFSS Data at State Health Compare
Visit State Health Compare to explore national and state-level estimates for the following measures that also come from the BRFSS:

Income Inequality
Sales of Opioid Painkillers
Adult Cancer Screenings
Chronic Disease Prevalence
Activities Limited due to Health Difficulty
Adult Obesity
Adult Binge Drinking
Adult Smoking
Adult E-Cigarette Use (New Measure)

State Health Compare also features a number of other indicator categories, including: health insurance coverage, cost of care, access to and utilization of care, care quality, health behaviors, health outcomes, and social determinants of health.

Related Reading
Now Available on State Health Compare: Eleven Updated Measures and One Brand New Measure
Educational Attainment and Access to Health Care: 50-State Analysis
Fifty-State Analysis Finds Lower Access to Care among Adults with Less Education

SHADAC Staff

p 612.624.4802
e shadac@umn.edu

Now Available on State Health Compare: Eleven Updated Measures and One Brand New Measure

Estimates for measures from a variety of categories (Health Outcomes, Health Behaviors, Access to Care, Cost of Care, and Social and Economic Factors, etc.) have now been updated on SHADAC’s State Health Compare web tool. All measures now contain data for 2018, the most recent year available. State Health Compare has also added a brand new measure, Adult E-Cigarette Use.

Updated Measures Include:

Income Inequality
Using the Gini coefficient (a summary of the dispersion of income across the entire income distribution), this measure gauges disparities in income in each state on a scale from 0 to 1, with higher values indicating greater inequality and lower values indicating the opposite. Estimates for all states are now available from 2006 through 2018.

Sales of Opioid Painkillers
This measure captures the rate of legal prescription opioid painkiller sales in kilograms per 100,000 people per year for both hydrocodone and oxycodone—the most common types of prescription opioids. Data is now available for all states from 2000 through 2018.

Adults Who Forgo Needed Medical Care*
The measure indicates the percent of adults (18+) in each state who could not get needed medical care due to cost. Breakdowns by education level and race/ethnicity are available for all states from 2005 through 2010 and 2011 through 2018.

Adults With No Personal Doctor*
This measure denotes the percent of adults without a personal doctor and is now available for all states from 2005 through 2010 and 2011 through 2018. Breakdowns by education level and race/ethnicity are also available.

Adult Cancer Screenings*
The measure is an indication of the percent of adults who have received recommended cancer screenings (e.g., colorectal screenings, mammograms, pap smears, etc.) in the past year, and is now available for all states from 2005 through 2010 and 2011 through 2018.

Chronic Disease Prevalence*
This measure captures the percent of adults who reported having one or more common chronic conditions such as diabetes, cardiovascular disease, heart attack, stroke, and asthma, in each state. Estimates are now available for all states from 2005 through 2010 and 2011 through 2018.

Activities Limited due to Health Difficulty*
This measure reports the average number of days (in the last 30 days) for which an adult indicates limited activity due to mental or physical health difficulties. It is now available for all states from 2005 through 2010 and 2011 through 2018.

Adult Obesity*
The measure is an indication of the prevalence of obesity, defined as a Body Mass Index (BMI) > 30, among the adult population 18 years of age and over. It is now available for all states from 2005 through 2010 and 2011 through 2018.

Adult Binge Drinking*
This measure indicates the percent of adults who, on one occasion, have consumed at least four drinks (women) or five (men) or more in the past 30 days. Now available for all states from 2005 through 2010 and 2011 through 2018, the measure includes breakdowns by education level and race/ethnicity.

Adult Smoking*
This measure indicates the percent of adults over 18 years of age who have smoked 100 or more cigarettes in their lifetime, and who currently smoke some days or every day. It is now available for all states from 2005 through 2010, and 2011 through 2018.

Adult E-Cigarette Use (Newly available measure on State Health Compare)
This measure indicates the percent of the adult population (18 years of age and over) who currently use e-cigarette some days or every day. It is now available for all states from 2016 through 2017 and for most states for 2018. Breakdowns are available by education level and race/ethnicity.

Data Sources
The State Health Compare estimates for income inequality come from the American Community Survey (ACS); the sales of opioid painkillers comes from the U.S. DEA’s Automated Reports Consolidated Ordering System Retail Drug Summary Reports; and the measures of chronic disease prevalence, activities limited due to health difficulty, and the adults who forgo needed medical care, adults with no personal doctor, and adult cancer screenings, obesity, binge drinking, smoking, and e-cigarette use measures all come from the Behavior Risk Factor Surveillance System (BRFSS).

Notes
All measures marked with an “*”: This indicates a break in series due to the BRFSS implementing cell phone sampling and an advanced weighting method in 2011.

Au-Yeung, Caroline
Research Fellow

p 612-625-2492
e butle180@umn.edu

New SHADAC Brief Explores National and State Estimates of Gains in Equitable Coverage for Mental Health and Substance Use Disorder under the ACA

A new brief from SHADAC, supported by the California Health Care Foundation (CHCF), examines gains in equitable coverage (i.e., “parity”) for mental health and substance use disorder (MH/SUD) treatment for people in the individual and small-group markets as well as those covered under Medicaid expansion after the passage of the Affordable Care Act (ACA). National and state-level estimates of parity gains for both types of treatment are provided within the brief, and estimates are broken down for the individual market, the small-group market, and the Medicaid expansion population.^[1] These estimates provide important context for policymakers and others engaged in the ongoing debate about repealing, modifying, or replacing the ACA.

Background
Before the ACA, national legislation regarding equitable coverage for MH/SUD treatments applied only to large-group (i.e., employer-sponsored) health plans, as a result of the Mental Health Parity Act of 1996 (MHPA) and the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). The ACA extended these MH/SUD parity protections beyond the large-group market to the individual and small-group markets and to Medicaid expansion beneficiaries by making MH/SUD treatments an essential health benefit (EHB). Before this change, coverage and parity for MH/ SUD treatment in these markets were addressed unevenly across states through a patchwork of state laws.

Expanding Equitable Coverage of Mental Health and Substance Use Disorder Treatment under the ACA: Key Provisions

Findings
Mental Health
In total, an estimated 39 million individuals nationwide had health insurance that was subject to the ACA’s expanded MH parity requirements as of 2017. Of these, 12.1 million were enrolled in individual plans, 14.4 million were enrolled in small-group plans, and almost 13 million were newly eligible Medicaid expansion enrollees.

At the state level, California saw the greatest number of individuals affected at approximately 8.6 million. Other states that had high estimates of affected populations included New York with 2.1 million, Florida with 2.08 million*, Texas with 1.9 million*, and Pennsylvania with 1.87 million.

Vermont, which had pre-ACA parity in both the individual and small-group market and had expanded Medicaid in advance of the ACA, was the only state that saw no effect. Other states such as Wyoming*, Alaska, and Delaware, all had affected populations of less than 100,000 (44,000; 67,000; and 80,000, respectively).

Substance Use Disorder
In total, an estimated 36.4 million individuals nationwide had health insurance that was subject to the ACA’s expanded SUD parity requirements as of 2017. Of these, 9.8 million were enrolled in individual plans, 14 million were enrolled in small-group plans, and almost 12 million were newly eligible Medicaid expansion enrollees.

At the state level, California saw the greatest number of individuals affected at approximately 8.26 million, followed by New York (2.09 million), Florida* (1.79 million), Pennsylvania (1.79 million) and Texas* (1.7 million).

Massachusetts, which had pre-ACA parity in both the individual and small-group market and had expanded Medicaid in advance of the ACA, was the only state that saw no effect. Other states such as Delaware, Wyoming*, Maine*, and Alaska all had affected populations of less than 100,000 (12,000; 39,000; 52,000; and 64,000, respectively).

Discussion
Though the ACA mandated access to health insurance coverage with parity for treatment of mental health and substance use disorders for new groups, it is important to note that the expansion of coverage parity legislation does not guarantee access to equitable MH/SUD services unless the legislation is enforced. Responsibility for parity enforcement falls primarily to states, and the nature and extent of enforcement is consequently inconsistent across the country, with many parity violations continuing to occur as state regulators face limitations in their enforcement capacities.

Further Reading
Access and Cost Barriers to Mental Health Care, by Insurance Status, 1999-2010
Kathleen Rowan, Donna McAlpine, and Lynn Blewett

Section 1115 Waivers and ACA Medicaid Expansions: A Review of Policies and Evidence from Five States: May 2016
SHADAC Special Issue Brief

Medicaid Expansion: Comparing State Choices in Alternative Benefit Plan Design
Colin Planalp

To learn more about mental health and state-level estimates for the affected population who report mentally unhealthy days, see our recent blog post, and visit State Health Compare to learn more about the measure and its data sources.