Friday, March 13, 2015
Kaiser Family Foundation
March 11, 2015
Consumer Assets and Patient Cost Sharing
By Gary Claxton, Matthew Rae, and Nirmita Panchal
While concerns about cost sharing are not new, the recent coverage
expansions under the ACA put a new focus on what it means for coverage
to be affordable. The goal of the law was to cover more of the
uninsured, many of whom have limited means. The law requires most people
to have health insurance, if they can afford to pay the premium, or to
pay a penalty. The issue for some families, however, is that the
policies with affordable premiums may have cost sharing requirements
that would be difficult for them to meet when they access services. Many
of the policies in the state and federal marketplaces have significant
cost sharing, as do many policies provided to people at work. The ACA
provides cost-sharing assistance to some, primarily to those with
incomes below 200 percent of poverty purchasing through a state or the
federal marketplace. Others potentially face much higher out-of-pocket
Overall, three in five (63%) households have enough liquid financial
assets to meet the lower deductible amounts ($1,200 single/$2,400
family) while one-half (51%) can meet the higher deductible amounts
($2,500 single/$5,000 family). These percentages are similar for
single-member and multi-member households, but vary significantly by
family income. Only 32% of households with incomes between 100% and 250%
of poverty can meet the lower deductible amounts, while one-in-five can
meet the higher deductible amounts. In contrast, 88% of households with
incomes over 400% of poverty can meet the lower deductible amounts and
three-in-four (79%) can meet the higher amounts.
Out-of-pocket limits are higher than deductibles and meeting them is
more difficult for many families. Forty-eight percent of households have
enough liquid financial assets to meet the lower out-of-pocket limits
($3,000 single/$6,000 family) and 37% can meet the higher limits ($6,000
single/$12,000 family). The percentages are quite low for households
with incomes between 100% and 250% of poverty, with 18% having enough
liquid financial assets to meet the lower out-of-pocket limits and 11%
being able to meet the higher limits. Among households with incomes over
400% of poverty, 75% have enough liquid financial assets to meet the
lower out-of-pocket limits while just 62% can meet the higher limits.
Many non-elderly, non-poor households lack the resources to meet the
deductibles and out-of-pocket limits that they may encounter in the
private insurance market. Many households have insufficient liquid
financial assets to meet the specified cost sharing measures, and the
situation for net financial assets is no better. Not surprisingly, the
difficulties are greater in households with lower incomes and with
someone who lacked health insurance.
While the ACA provides for reduced cost sharing for some people with
incomes below 250% of poverty that purchase coverage in a state or the
federal marketplace, there is no assistance with cost sharing for those
with higher incomes or for those obtaining coverage through a job.
Substantial shares of households with incomes between 250% and 400% of
poverty would be unable to meet even the lower out-of-pocket limits with
their current resources, and meaningful shares of households with
incomes over 400% of poverty would have problems as well.
Comment by Don McCanne
This important study demonstrates one of the most serious deficiencies
in our dysfunctional system of health care financing: the mismatch
between the personal financial assets that most Americans have and the
cost sharing in the form of deductibles and out-of-pocket limits
required by their insurance plans. Far too many individuals, should they
have significant medical needs, do not have adequate liquid assets to
cover the level of cost sharing required by most plans today.
Look at the most favorable example above: 25% of higher-income families
(families with incomes over 400% of poverty) do not have enough liquid
financial assets to pay lower out-of-pocket limits of $3,000
single/$6,000 family. Worse, 38% of these higher-income families do not
have enough liquid assets to pay higher out-of-pocket limits of $6,000
single/$12,000 family (the 2015 out-of-pocket limits for plans in the
ACA exchanges are even higher: $6,600 individual/$13,200 family).
Further, net financial assets are usually lower than liquid financial
assets because of family debt; families are even more broke than their
cash on hand would indicate.
Except for those with the very highest incomes, our current flawed
system of financing health care through private plans creates financial
hardship for far too many of us who require significant amounts of
health care. Today's private insurance products are inadequate.
What is the source of support for this deficient coverage? Private
insurers want to maintain access to markets by keeping their premiums
competitive. They do this partly by shifting costs to patients' pockets.
Neoliberal and conservative politicians want to keep spending on
government premium subsidies to a minimum, so they support cost sharing
policies that reduce premiums. Libertarian and conservative ideologues
want to place health care consumers in charge of spending their own
money. If they don't have enough funds, well, that's too bad. They
should have had enough personal responsibility to establish their own
health savings accounts and fully fund them before medical needs arose.
Private insurers we can certainly do without. But what about the
ideologues? Is there no place in this country for egalitarianism and
social solidarity? I cringe when I think about current trends advancing
income and wealth inequality as the social fiber continues to shred.
We desperately need a single-payer, improved Medicare for all, with
first dollar coverage. Let's harness the forces of social solidarity so
we can achieve that goal.
at 1:56 PM