Most Low-Healthcare Users Are Healthy, Satisfied With Access

Diana Swift

April 03, 2017

The majority of the US population incurs very few out-of-pocket expenditures for healthcare, a spending level that has been stable for decades and remains unchanged since the inception of the Affordable Care Act (ACA). And among members of the low-spending vast majority, most perceive themselves as healthy and report no problems or delays in accessing care.

The findings, published online April 3 in Health Affairs, come from an analysis of US households' nonpremium healthcare expenditures from 1977 to 2014. Mark L. Berk, PhD, a health policy researcher and contributing editor to Health Affairs in Bethesda, Maryland, and Zhengyi Fang, a senior programmer and analyst for the Health Policy and Data Analysis Group at Social and Scientific Systems, Silver Spring, Maryland, conducted secondary analyses of 21 surveys conducted by the Agency for Healthcare Research and Quality over the course of almost 40 years.

"Our study shows that there were important reasons why we moved into mandated coverage," Dr Berk told Medscape Medical News. "And if you take away the insurance mandate, it's going to be very hard to finance the care of the small number of people who need a large amount of care."

The study compared healthcare spending by US adults in the bottom 50% of expenditures with that of those in the top 50%, and also estimated expenses for the 1% of spending at the highest level. It was based on 19 of the Agency for Healthcare Research and Quality's annual Medical Expenditure Panel Surveys, conducted from 1996 to 2014, as well as two earlier surveys: the National Medical Care Expenditure Survey of 1977 and the National Medical Expenditure Survey of 1987.

The analysis also examined respondents' self-reported health status, insurance coverage, age, out-of-pocket expenditures, and access to care, the last based on whether respondents reported receiving all necessary care and experiencing any delays in getting care.

Over the course of 37 years, healthcare spending by those in the bottom half of spenders never accounted for less than 2.7% or for more than 3.5% of the total. And in 2014, the bottom 75% of the population by spending group incurred just 13.4% of all healthcare expenditures, whereas the highest-spending groups (1%) used approximately 25%. "Over the entire thirty-seven-year study period, the top 1 percent of the population has consistently incurred much greater expense than the bottom three-fourths," the researchers write.

"These findings show just how dramatic the transfer is. If 5% of the population are using the most of the care and 1% are using over 25%, you really do need a system that includes people whose claims are low, and that is the vast majority," Dr Berk told Medscape Medical News.

He added that an element of "confusing distortion" has entered the current debate over healthcare reform, with ACA opponents critical of the fact that the plan makes healthy people pay for sick people. "That criticism goes against everything we know about insurance," Dr Berk said. "With life insurance, for example, it's the people who live that pay the [beneficiaries] of those who die."

According to previous analysis published in Health Affairs, the top 1% of the population accounted for 26% to 30% of all healthcare spending on noninstitutionalized services during 1970 to 1996. Conversely, the bottom 50% was responsible for just 3% to 4% of such expenditures.

As for recent out-of-pocket expenditures, in 2014, those in the lower spending half spent an average of $75, which is less than the $94 (adjusted 2014 dollars) spent in 1977. In contrast, high spenders averaged $1096 in 2014 out-of-pocket expenditures. And although nearly 50% of low spenders had no out-of-pocket costs, only 6.1% of high spenders did.

In terms of spending group ages, not surprisingly, 31% in the bottom half were younger than 18 years compared with about 16% in the top half, and although 5% of low spenders were aged 65 years and older, 25% of high spenders were seniors, and 38% in the highest-spending group were elderly. "While age is certainly associated with cost, the elderly clearly did not make up the majority of the highest spenders," the authors write.

Self-perceived health status also varied by spending group, with low spenders generally believing they were healthy. In 2014, 5% of these reported fair or poor health compared with about 17% of high spenders. Nearly 16% of low spenders lacked health insurance coverage in 2014, down from about 21% in 2013, whereas fewer than 4% of high spenders lacked any coverage that year, a drop from 5% the year before.

Although nearly one in three low spenders did not have a usual source of care, fewer than 7% reported lacking immediate access to care. In contrast, high spenders were more than twice as likely to report problems accessing immediate care, and more than 21% of the highest spenders reported difficulties.

The authors note that although policy discussions on reducing healthcare spending have focused on people with high expenses, those with the lowest healthcare spending will be important factors in the viability of the ACA and any replacement acts proposed by the current presidential administration.

"This is a population whose low use of services has remained stable over time. If insurance coverage of this group declines, insurers' ability to offer affordable coverage to high spenders with greater need will also decline," the authors write, adding that monitoring the low-expenditure population will be essential to any evaluation of healthcare reform.

Interestingly, they pointed out, a 2016 article published in Health Affairs noted a shift in the US population from need-based to income-based use of healthcare services.

The authors have disclosed no relevant financial relationships.

Health Aff. 2017;36(4):742-746. Abstract

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