KFF designs, conducts and analyzes original public opinion and survey research on Americans’ attitudes, knowledge, and experiences with the health care system to help amplify the public’s voice in major national debates.
The Deficit Reduction Act (DRA) of 2005 was signed into law in February 2006 with several significant changes to the Medicaid program affecting both health and long-term care coverage as well as new citizenship requirements.
States were granted greater flexibility in charging copayments and premiums and modifying the benefit package for certain Medicaid beneficiaries. Changes of this type previously required a waiver and now can be done by amending the state plan. The first two states to modify their Medicaid programs in response to the DRA were West Virginia and Kentucky; other states are likely considering changes.
On Monday, June 19, 12 p.m., ET, the Kaiser Family Foundation’s Commission on Medicaid and the Uninsured (KCMU) is holding a background briefing for reporters across the country on understanding what changed for Medicaid in the DRA, how West Virginia and Kentucky are planning to modify their Medicaid programs and what are the implications of DRA-related state actions. The briefing features Diane Rowland, executive vice president of the Kaiser Family Foundation and executive director of KCMU, and other Kaiser experts.
To dial in to the briefing, call 800-379-9582. The password is KCMU.
Washington Post/Kaiser Family Foundation/Harvard African-American Men Survey
TheWashington Post, the Kaiser Family Foundation and Harvard University have released a new, comprehensive survey looking at how African-American men view their lives in the United States and their outlook for the future. The survey gauges the views and experiences of African-American men on marriage and family, education, careers and health, among other issues, and includes comparisons to the views and experiences of African-American women and white men and women.
The African-American Men Survey is the 15th survey in a series generated under a three-way partnership between TheWashington Post, the Kaiser Family Foundation and Harvard University. The three organizations work together to pick the survey topics, design the survey instruments and analyze the results. The survey’s findings were published in the June 4, 2006, edition of TheWashington Post.
This survey was conducted by telephone from March 20 to April 29, 2006, among 2,864 randomly selected adults nationwide, including: 1,328 black men; 507 black women; 437 white men and 495 white women. Results for total respondents have been weighted so that black respondents are represented in proportion to their actual share of the population. Margin of sampling error is plus or minus 3 percentage points for results based on all respondents or black men, 5 percentage points for black women and 6 percentage points for white men or women. Hispanics and Asians were interviewed along with white and black respondents, but because of the relative size of those populations, there were not enough respondents to break out separately. The complete survey results and detailed methodology description are available in the toplines document.
This chart pack is a supplemental report based on a subset of the Survey of Americans on HIV/AIDS and provides additional analysis on public opinion on HIV testing. A full survey report, including full question wording for results presented in this report is available here.
This chartpack is a supplemental report based on a subset of the Survey of Americans on HIV/AIDS and provides additional analysis on the opinions and experiences of 18- to 25-year-olds on HIV/AIDS. A full survey report, including full question wording for results presented in this report is available here.
How much people should pay out-of-pocket for health care is a much-debated issue in health policy. New health insurance products with higher out-of-pocket shares are becoming more evident in the private market, and some states are considering ways to increase enrollee financial responsibility in state Medicaid programs. This paper presents information about current out-of-pocket spending by individuals with the purpose of providing context for future health policy discussions.
Current proposals suggest that increasing the amount that people must pay directly out-of-pocket for their health care at the point of service will encourage them to make more efficient and better health care decisions, leading to an overall reduction in health care expenditures. Discussions about out-of-pocket responsibility often focus on the overall percentage of health expenditures that are paid out-of-pocket — roughly 20% based on the 2003 Medical Expenditure Panel Survey (MEPS).1 There is, however, considerable variation in the amounts and percentages that people pay out-of-pocket for health care today. The paper breaks out total and out-of-pocket expenditures along several dimensions, including level of spending, service type and poverty level for two population groups — all people and nonelderly people with private health insurance.2 Our goal is to enhance public understanding of how total and out-of-pocket health care expenditures are distributed across the population.
The information below is based on data from the 2003 Medical Expenditure Panel Survey (MEPS), Household Component. MEPS is a national probability survey of the U.S. civilian population residing outside of institutions, conducted by the Agency for Healthcare Research and Quality. The survey provides detailed information on the demographic characteristics, health care use and health care expenditures costs for this population. See http://www.meps.ahrq.gov/Puf/PufDetail.asp?ID=194/ for additional description of the 2003 MEPS consolidated file.
This paper focuses on expenditures paid for health care services and not on premiums paid by families. Current discussions about changing health benefit design focus on out-of-pocket payments for services, so this paper looks at out-of-pocket costs in that context. Premium payments are clearly an important part in considering the overall out-of-pocket health care burden on families (and premium levels will interact with changes in benefit design). We will be looking at the broader issue of overall out-of-pocket burden and family budgets in later work.
Share of Total Expenditures Paid Out-of-Pocket
Figure 1 shows that about 20% of total health expenditures are paid out-of-pocket. This percentage is consistent across the two populations presented here.3
Average Out-of-Pocket Share
Figure 2 shows the percentage of expenditures that the average person who has spending on health care pays out-of-pocket, which is 35% and 34% for each of the two populations. These percentages are higher than the 20% and 19% presented above because health expenditures are not distributed evenly across the population — a small percentage of people account for most health expenditures, and these high spenders have relatively low out-of-pocket shares. More information on out-of-pocket shares by level of total spending is presented below.
Out-of-Pocket Shares By Poverty Level
Figure 3 shows that, among people with health spending, the average out-of-pocket share for people under poverty is somewhat lower (28% v. 35-36%) for all people than the average out-of-pocket share above poverty. This difference may result from cost sharing protection provided for some of the poor by Medicaid and other public programs. Average out-of-pocket shares do not vary by family poverty level for the nonelderly group with private insurance.
Out-of-Pocket Shares by Level of Total Spending
A relatively small percentage of the population accounts for most health expenditures — the 5 percent with the highest spending account for about 49% of the total health expenditures, while the 20 percent with the highest spending account for around 80% of total expenditures.4 This distribution does not vary considerably by population group.
As Figure 4 shows, out-of-pocket spending accounts for a smaller proportion of total spending as the overall level of spending on health increases. Figure 4 shows average out-of-pocket shares for people based on their level of overall health spending.5 For example, looking at all people, the one percent with the highest health care spending had an average out-of-pocket share of seven percent and the four percent of people with the next highest level of spending (between one and five percent) had an average out-of-pocket share of 13%. There are several potential reasons for this pattern — high spenders are more likely to exceed the maximum out-of-pocket limits in their insurance, after which most of their costs are completely covered, low spenders are likely to have more of their spending in the deductible portion of their coverage, and high spenders are more likely to be using services, such as hospital care, where the out-of-pocket share of expenditures tends to be low (see next section).6Figure 5 shows the corresponding average out of pocket spending amounts by percentile of health spending. Note that the people with the lowest average out of pocket spending are still paying a substantial amount out-of-pocket because of their high overall spending. 7
Out-of-Pocket Shares by Type of Service
Public and private insurance plans vary their coverage and payment arrangements by type of health care service, resulting in differences in the share of expenses that are paid out-of-pocket by people for different services. Figure 6 shows the share that the average person with expenses in a health category pays out-of-pocket for health care services in that category. (Figure 6 shows information for all people; for comparable information for the nonelderly with private insurance) As the figure shows, out-of-pocket shares are low for inpatient and outpatient hospital services, which are relatively expensive, and higher for office-based, prescription drugs and other services.
Table 1 shows the same information broken out by people’s level of spending.8People with the highest expenditures on average pay relatively low shares of the costs for hospital, outpatient and office-based services; the average out-of-pocket shares for these services tend to rise as overall spending falls. People at all spending levels on average pay a relatively high share of the costs for prescription drugs, dental and vision services. (Table 1 provides information for all people by spending category; for comparable information for the nonelderly with private health insurance)
Table 1: Average Share Paid Out-of-Pocket by People with Health Spending,by Type of Service and Spending Level, All People, 2003
Type of Service
Out of Pocket Contribution to Total Health Spending in that category
in top 5%
Hospital
2%
Outpatient
5%
Office Based Visit
12%
Prescription Drugs
49%
Emergency Room
5%
Dental
50%
Home Health
13%
Vision
70%
Other Health Care
38%
in top 10% to 5%
Hospital
5%
Outpatient
9%
Office Based Visit
17%
Prescription Drugs
49%
Emergency Room
8%
Dental
52%
Home Health
13%
Vision
71%
Other Health Care
49%
in top 20% to 10%
Hospital
5%
Outpatient
9%
Office Based Visit
20%
Prescription Drugs
49%
Emergency Room
11%
Dental
48%
Home Health
33%
Vision
73%
Other Health Care
54%
in bottom 80%
Hospital
16%
Outpatient
15%
Office Based Visit
29%
Prescription Drugs
56%
Emergency Room
18%
Dental
39%
Home Health
33%
Vision
75%
Other Health Care
60%
Proportion Each Category of Service Adds to Average Person’s Out-of-Pocket Spending
Figure 7 shows how out-of-pocket spending is distributed to the average person with health care spending. Just over 40% of the average person’s out-of-pocket spending is for prescription drugs, and another quarter is for office-based visits. (Figure 7 shows information for all people; for comparable information for the nonelderly with private insurance)
Table 2 shows the same information broken out by people’s level of spending. For the people with the highest spending, hospital out-of-pocket spending makes up a larger share of their average out-of-pocket expenditures than it does for the people in lower spending categories. This is not surprising because people in the highest spending category have more hospitalizations on average and longer average hospital stays than people who spend less. For the average person in all spending categories, however, out-of-pocket spending for prescription drugs makes up the largest share of their out-of-pocket spending. (Table 2 provides information for all people by spending level; for comparable information for the non-elderly with private health insurance)
Table 2: Distribution of Out-of-Pocket Spending for Average Person with Health Spending,by Spending Level, All People, 2003.
Type of Service
Service Out of Pocket Contribution to Total Out-of-Pocket Spending
in top 5%
Hospital
9%
Outpatient
4%
Office Based Visit
14%
Prescription Drugs
57%
Emergency Room
1%
Dental
7%
Home Health
2%
Vision
2%
Other Health Care
3%
in top 10% to 5%
Hospital
5%
Outpatient
5%
Office Based Visit
19%
Prescription Drugs
51%
Emergency Room
2%
Dental
12%
Home Health
1%
Vision
3%
Other Health Care
2%
in top 20% to 10%
Hospital
3%
Outpatient
4%
Office Based Visit
19%
Prescription Drugs
50%
Emergency Room
2%
Dental
17%
Home Health
0%
Vision
4%
Other Health Care
1%
in bottom 80%
Hospital
0%
Outpatient
1%
Office Based Visit
29%
Prescription Drugs
39%
Emergency Room
3%
Dental
19%
Home Health
0%
Vision
8%
Other Health Care
1%
Table 1a: Average Share Paid Out-of-Pocket by People with Health Spending,by Type of Service and Spending Level, Nonelderly with Private Insurance, 2003
Type of Service
Out of Pocket Contribution to Total Health Spending in that category
in top 5%
Hospital
3%
Outpatient
7%
Office Based Visit
17%
Prescription Drugs
43%
Emergency Room
7%
Dental
40%
Home Health
10%
Vision
76%
Other Health Care
45%
in top 10% to 5%
Hospital
4%
Outpatient
11%
Office Based Visit
22%
Prescription Drugs
45%
Emergency Room
11%
Dental
41%
Home Health
17%
Vision
75%
Other Health Care
52%
in top 20% to 10%
Hospital
6%
Outpatient
11%
Office Based Visit
24%
Prescription Drugs
45%
Emergency Room
14%
Dental
41%
Home Health
50%
Vision
76%
Other Health Care
60%
in bottom 80%
Hospital
7%
Outpatient
17%
Office Based Visit
30%
Prescription Drugs
54%
Emergency Room
16%
Dental
35%
Home Health
59%
Vision
76%
Other Health Care
64%
Table 2a: Distribution of Out-of-Pocket Spending for Average Person with Health Spending,by Spending Level, Nonelderly with Private Insurance, 2003.
Type of Service
Service Out of Pocket Contribution to Total Out-of-Pocket Spending
in top 5%
Hospital
12%
Outpatient
7%
Office Based Visit
23%
Prescription Drugs
40%
Emergency Room
2%
Dental
11%
Home Health
0%
Vision
3%
Other Health Care
2%
in top 10% to 5%
Hospital
5%
Outpatient
6%
Office Based Visit
24%
Prescription Drugs
41%
Emergency Room
3%
Dental
16%
Home Health
0%
Vision
4%
Other Health Care
1%
in top 20% to 10%
Hospital
2%
Outpatient
5%
Office Based Visit
24%
Prescription Drugs
39%
Emergency Room
3%
Dental
22%
Home Health
0%
Vision
5%
Other Health Care
1%
in bottom 80%
Hospital
0%
Outpatient
1%
Office Based Visit
33%
Prescription Drugs
33%
Emergency Room
2%
Dental
21%
Home Health
0%
Vision
8%
Other Health Care
0%
Notes:
1. The estimated percentage of out-of-pocket spending for personal health care published by the Centers for Medicaid and Medicare Services for the National Health Accounts (NHA) is slightly lower at 15% in 2004. The NHA estimate accounts for some expenditures not included in MEPS, such as nursing home care and other institutional settings. (See Borger et al, Health Spending Projections Through 2015. Health Affairs 25(2006): w61-w73. Accessed at:http://content.healthaffairs.org/cgi/reprint/hlthaff.25.w61v1.pdf)
2. Nonelderly with private health insurance are people who are age 64 and under and have more than six months of either of these three general types of coverage: 1) private employer group or TRICARE; 2) private nongroup or private self employed group of one; or 3) private other group, private don’t know, or private coverage from someone outside of the household.
3. The category “health coverage and other sources” includes any spending by Medicare, Medicaid, private insurance, Veteran’s Administration, TRICARE, other federal sources, other state and local sources, workers’ compensation, other private, other public, or other unclassified sources.
5. Spending levels are calculated in a multi-step process. First we identify the expenditure values that are associated with the following percentiles: 99%, 95%, 90%, and 80%. For instance, the 99 th percentile of spending for all people is $36,278. People whose expenditures are at that level or higher are considered to be in the top 1% of spending. We identified people in the 5% to 1% (but not including 1%) spending category by using the expenditure level associated with the top 95 th percentile of spending (those who spend at least $12,041) and subtracting out those who spend $36,278 or more. This process continues until all people have been grouped according to spending level. People with no (zero) expenditures in the year fall in the ‘lowest 80 th percentile of health spending’.
6. People with no (zero) health expenditures are included in the calculation of percentiles of health spending (see footnote #5) but only people with health expenditures are included when calculating the percentage of expenditures that are out-of-pocket.
7. People with no (zero) health expenditures are not included in the average out-of-pocket spending amounts.
8. As noted earlier, people with no (zero) health expenditures are included in the calculation of percentiles of health spending (see footnote #5) but only people with health expenditures are included when calculating the percentage of expenditures that are out-of-pocket.
This report analyzes Medicaid enrollment and spending trends for the years 2000-2004. Rising enrollment and health care inflation produced most of Medicaid’s spending increases during the period. Even with a stronger economy, however, Medicaid’s enrollment pressures remain due to demographic trends and continued declines in employer sponsored insurance.
A new fact sheet and report analyze Medicaid spending and enrollment trends for 2000-2004. Medicaid trends are related to the state of the nation’s economy, and as the economy has strengthened, increases in enrollment and spending have slowed. Rising enrollment and health care inflation produced most of Medicaid’s spending increases. Even with a stronger economy, however, Medicaid’s enrollment pressures remain due to demographic trends and continued declines in employer-sponsored insurance.
This Kaiser survey report looks at how the bankruptcies of two steel companies, the LTV Corporation and Bethlehem Steel, affected health coverage for the companies’ retirees and dependents. The bankruptcies left about 200,000 retirees and spouses without retiree health coverage in 2002 and 2003. The report provides insight into the impact of a tax credit enacted by Congress in 2002 to provide temporary assistance to workers and retirees in “distressed” industries, including the steel industry.
The 2004 survey found that nearly three quarters of the retirees who responded had obtained replacement coverage or a supplement to their Medicare coverage, although many reported that the loss of benefits caused a significant disruption to their retirement.
This survey sample included 2,691 retirees or surviving spouses, including both early retirees ages 64 and younger in Pennsylvania, Indiana, Ohio and Maryland and Medicare-age retirees 65 in the states of Indiana and Ohio. The United Steelworkers of America assisted in the survey by providing information needed to identify affected retirees and surviving spouses for participation in the survey.
June 5, 2006, marks twenty-five years since the U.S. Centers for Disease Control and Prevention issued its first warning about an emerging illness that soon became known as AIDS. In recognition of this day, the Kaiser Family Foundation is releasing several new and updated resources:
The Global HIV/AIDS Timeline is an interactive, up-to-date web-based timeline of key HIV-related events and noteworthy activities from 1981 through today.
The Survey of Americans on HIV/AIDS released May 2006 finds that Americans increasingly believe the U.S. should be a global leader on HIV/AIDS, including spending more money to fight the epidemic abroad and at home.
GlobalHealthReporting.org provides the most current news headlines and resources for journalists and others in global health and its facts-at-a-glance, overview of the HIV/AIDS global epidemic, and country profile pages have been updated to reflect the most current data from UNAIDS.
GlobalHealthFacts.org has been updated with new HIV/AIDS data by country. The site provides country comparisons and interactive maps and all data can be downloaded. GlobalHealthFacts also has the latest data on tuberculosis, malaria, avian flu and other health and demographic indicators.
Up-to-date, state-by-state data on the HIV/AIDS epidemic in the United States is available on statehealthfacts.org.
Resources on HIV/AIDS on KaiserEDU.org include narrated slide tutorials on the HIV/AIDS epidemic, reference libraries with the latest research and policy analysis, an issue module for students interested in volunteering on the HIV/AIDS epidemic, and a collection of course syllabi from classes on HIV policy.
May 1-7, 2006, is Cover the Uninsured Week, organized by The Robert Wood Johnson Foundation and several partner organizations. The Kaiser Family Foundation has a wide range of resources on the topics of health coverage and the nation’s uninsured population to assist you in your work related to these issues.
The Robert Wood Johnson Foundation launches the Week at a May 2 event in Washington, D.C.
