Access to Health Care By Low Income Adults: Health Insurance Status and Trajectories of out-of-Pocket Costs

Background/Purpose: Many studies have investigated how access to care and use of health care services among low-income adults vary by insurance status. The low income adults, and to a considerable extent the near-poor, have limited access because of copayments and deductibles that are typically part of private insurance coverage. Although most of the low-income adults have been covered under Medicaid, there still are many uninsured individuals who tend to forgo purchasing health insurance plan and become exposed to high out-of-pocket cost burdens if they become ill. Surprisingly, little is known about how these health plan choices are associated with out-of-pocket costs over years. Furthermore, poverty and insurance status are intertwined; therefore, this study examine the relationship between health insurance status and out-of-pocket expenditure among low-income middle-aged adults, taking into account their income and health status over ten years.  

Method: Data came from six waves of the Health and Retirement Study (HRS, 2002-2012). We restricted our sample to middle-aged adults between age 51 and 64 living below 250% of the federal poverty (Observations=5,307; N=1,384). We included six measures of health insurance, measured as time-varying indicators for the past 10 years (constantly Medicaid, constantly private, constantly uninsured, changed from insured to uninsured, changed from uninsured to insured, and constantly other insurance types). For health care cost trajectories, we examined out-of-pocket health care expenditures which included any inpatient and outpatient care costs, doctor visits, and prescription drug expenditures. We also considered distinct poverty types according to the length and depth of poverty and examined their associations and interactions with health insurance status and health care costs. A random coefficient regression model in multi-level growth curve framework was used to analyze the associations.

Results: Those who constantly were on Medicaid were less likely to spend while those who constantly had private insurance tended to spend more. Although those who were constantly on Medicaid spent less, if they were poor (below100% of the federal poverty line), they became more likely to spend. Those who were ever poor during the 10 years and had either constantly private insurance or were constantly uninsured reported higher out-of-pocket expenditures. Even if they were on constantly Medicaid, if they fell below the poverty line for more than half the observation years, they became exposed to higher cost burdens. Interestingly, those who were consistently uninsured and were poor for more than six years were less likely to spend over time because they may have used relatively few health services, except when they were seriously ill.

Conclusion: Our findings on the high cost of health care coverage are consistent with evidence that the low-income adults have limited health care access.