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STATISTICAL BRIEF #450:
Differentials in the Concentration in Out-of-Pocket Health Expenditures across Population Subgroups in the U.S., 2012

September 2014

Steven B. Cohen, PhD

Highlights

In 2012, the top 1 percent ranked by their out-of-pocket health care expenses accounted for 20.5 percent of total out-of-pocket health care expenditures with an annual mean out-of-pocket expenditure of $12,500. Overall, the top 50 percent of the population ranked by their out-of-pocket expenditures accounted for 97.8 percent of overall out-of-pocket health care expenditures while the lower 50 percent accounted for only 2.2 percent of the total.
In 2012, 7.2 percent of the population (22.5 million individuals) had out-of-pocket expenditures for medical care that were equal to or greater than $2,000. Nearly 4.8 million individuals (1.5 percent) paid $5,000 or more out of pocket for their medical care. When considering higher spending thresholds, approximately 1.3 million individuals (0.4 percent) incurred out-of-pocket expenditures of at least $10,000.
In 2012, only 3.9 percent of medical expenditures for inpatient hospitalizations were paid out of pocket. Alternatively, 12.3 percent of ambulatory care expenditures, 19.2 percent of prescribed medical expenditures, and 48.5 percent of dental expenditures were paid out of pocket.
Children under the age of 18 were characterized by substantially greater concentrated levels of out-of-pocket health care spending relative to their older counterparts. Alternatively, the elderly had the highest mean levels of out-of-pocket health care expenditures relative to younger population subgroups at the top quantiles of the expenditure distribution.
Non-Hispanic whites and other races had the highest mean levels of out-of-pocket health care expenditures at the top quantiles compared with other racial/ethnic groups.
The top 5 percent of the publicly insured population under age 65 ranked by their health care expenses accounted for 68.1 percent of the out-of-pocket health care expenditures incurred by this subpopulation with an annual mean of $2,682. Individuals with public insurance had the most concentrated levels of out-of-pocket health care expenditures and the lowest annual mean out-of-pocket expenses.

Introduction

Estimates of health care expenses for the U.S. civilian noninstitutionalized (community) population are critical to policymakers and others concerned with access to medical care and the cost and sources of payment for that care. In 2012, health care expenses among the U.S. community population totaled $1.35 trillion. Medical care expenses, however, are highly concentrated among a relatively small proportion of individuals in the community population. As previously reported in 1996, the top 1 percent of the U.S. population accounted for 28 percent of the total health care expenditures and the top 5 percent for more than half. More recent data have revealed that over time there has been some decrease in the extent of this concentration at the upper end of the expenditure distribution. In 2012, nearly 14 percent of health care expenditures in the community population for medical care were paid out of pocket ($191 billion). Similarly, the distribution of health care expenditures paid out of pocket is also concentrated among a relatively small proportion of individuals.

Using information from the Household Component of the Medical Expenditure Panel Survey (MEPS-HC) for 2012, this Brief provides detailed estimates of the concentration in the level of out-of-pocket health care expenditures for the nation, and further distinguished by specific population subgroups. Studies that examine the concentration of health care expenditures, their magnitude, and their respective differentials among specific population subgroups are essential to help discern the factors most likely to drive health care spending and the characteristics of the individuals who incur them. The MEPS-HC data are particularly well suited for measuring the population's distribution of health care expenditures. All differences between estimates discussed in the text are statistically significant at the 0.05 level unless otherwise noted.

Findings

In 2012, the top 1 percent ranked by their health care expenses paid out of pocket accounted for 20.5 percent of total health care expenditures paid out of pocket with an annual mean out-of-pocket expenditure of $12,500 (figure 1). The top 5 percent of the population accounted for 45.1 percent of total out-of-pocket expenditures with an annual mean out-of-pocket expenditure of $5,501. In addition, the top 10 percent of the population accounted for 61.3 percent of total out-of-pocket expenditures with an annual mean out-of-pocket expenditure of $3,741. Overall, the top 50 percent of the population ranked by their out-of-pocket expenditures accounted for 97.8 percent of overall out-of-pocket health care expenditures while the lower 50 percent accounted for only 2.2 percent of the total. Those individuals ranked in the top half of the out-of-pocket health care expenditure distribution had an annual mean out-of-pocket expenditure of $1,192.

In 2012, 67.2 percent of the population (22.5 million individuals) had out-of-pocket expenditures for medical care that were equal to or greater than $2,000. Nearly 4.8 million individuals (1.5 percent) paid $5,000 or more out of pocket for their medical care. When considering higher spending thresholds, approximately 1.3 million individuals (0.4 percent) incurred out-of-pocket expenditures of at least $10,000. In addition, the elderly were 2.3 times as likely as their younger counterparts to have experienced out-of-pocket expenditures at or above $2,000 (14.0 percent relative to 6.1 percent, figure 2).

Of the $483.7 billion spent on ambulatory care in 2012, $59.4 billion or 12.3 percent was spent out of pocket (figure 3). Relative to the $409.1 billion spent on hospital inpatient care, only 3.9 percent ($16.0 billion) was paid out of pocket. Spending on prescription medications totaled $293.0 billion, with $56.1 billion or 19.2 percent paid out of pocket. Alternatively, 48.5 percent (41.1 billion) of the $84.8 billion in medical expenditures for dental care was paid out of pocket.

Relative to the total out-of-pocket medical expenditures incurred in 2012 ($191 billion), nearly one-third of these expenses were attributable to ambulatory care ($59.4 billion), similar to the proportion associated with out-of-pocket costs for prescribed medicines ($56.1 billion, figure 4). Another one-fifth of out-of-pocket expenditures were for dental care ($41.1 billion), with the remainder attributable to hospital inpatient care ($16.0 billion) and other medical services ($18.5 billion of which $4.9 billion was for home health).

Age
In 2012, the top 5 percent of children under the age of 18 ranked by their out-of-pocket health care expenses accounted for 60.5 percent of the out-of-pocket health care expenditures incurred by this subpopulation with an annual mean out-of-pocket expenditure of $3,287 (figure 5). Among persons 18–44 years old, the top 5 percent accounted for 47.8 percent of the out-of-pocket health care expenditures incurred by this population subgroup with an annual out-of-pocket mean of $3,977. The top 5 percent of individuals 45–64 were associated with 38.2 percent of the out-of-pocket health care expenditures incurred by this age group with an annual out-of-pocket mean of $6,519. The top 5 percent of the elderly aged 65 years and older accounted for 38.8 percent of the out-of-pocket medical expenditures experienced by this domain, with an annual mean of $9,274. In summary, the youngest age cohort (under 18 years old) was characterized by the most concentrated levels of out-of-pocket health care spending. In contrast, the elderly had the highest mean levels of out-of-pocket health care expenditures relative to younger population subgroups at the highest quantiles of the out-of-pocket health care expenditure distribution.

Race/ethnicity
The top 5 percent of non-Hispanic whites and other races accounted for 41.2 percent of the out-of-pocket health care expenditures incurred by this subpopulation with an annual mean out-of-pocket expenditure of $6,245 in 2012 (figure 6). Among non-Hispanic black individuals, the top 5 percent accounted for 56.1 percent of the out-of-pocket health care expenditures for this subgroup, with an annual mean of $4,039. For non-Hispanic Asians, the top 5 percent were associated with 46.9 percent of the out-of-pocket health care expenditures incurred for this subpopulation, exhibiting a mean of $3,792. The top 5 percent of Hispanics accounted for 57.0 percent of out-of-pocket health care expenditures by this subpopulation with an annual mean of $3,179. Non-Hispanic whites and other races had the highest mean levels of out-of-pocket health care expenditures at the top quantiles when controlling for race/ethnicity.

Sex
In 2012, the top 5 percent of males accounted for 47.0 percent of out-of-pocket health care expenditures incurred by this subpopulation with an annual mean of $4,901 (figure 7). Among females, the top 5 percent were associated with 43.5 percent of out-of-pocket health care expenditures for this subgroup, with mean out-of-pocket expenditures of $6,061. Females had higher mean levels of out-of-pocket health care expenditures at the top quantiles compared to males.

Insurance status
The top 5 percent of the uninsured population under age 65 ranked by their health care expenses accounted for 55.5 percent of the out-of-pocket health care expenditures incurred by this subpopulation with annual mean out-of-pocket expenditures of $5,087 in 2012 (figure 8). Among non-elderly persons with public coverage only, the top 5 percent accounted for 68.1 percent of out-of-pocket health care expenditures for this subgroup, with mean expenditures of $2,682. For those non-elderly with any private coverage, the top 5 percent were associated with 41.4 percent of this group's out-of-pocket health care expenses, exhibiting a mean of $5,068. Individuals with public insurance had the most concentrated levels of out-of-pocket health care expenditures and the lowest annual mean out-of-pocket expenses.

Income
In 2012, the top 5 percent of the poor accounted for 61.2 percent of out-of-pocket health care expenditures incurred by this subgroup with an annual mean of $3,979 (figure 9). For near poor individuals, the top 5 percent were associated with 52.3 percent of out-of-pocket health care expenses for this subpopulation, exhibiting a mean of $4,359. Among low income persons, the top 5 percent accounted for 48.3 percent of this group's out-of-pocket health care expenditures, with an annual mean of $4,590. The top 5 percent of the middle income subgroup accounted for 45.6 percent of out-of-pocket health care expenditures and an annual mean of $5,467. For those persons in the high income subgroup, the top 5 percent were associated with 38.9 percent of out-of-pocket health care expenditures, exhibiting a mean of $6,383. The poor had a significantly more concentrated level of out-of-pocket health care expenditures than their high income counterparts.

Data Source

The estimates shown in this Statistical Brief are drawn from analyses conducted by the MEPS staff from the following public use file: MEPS HC-155, 2012 Full Year Consolidated Data File.

Definitions

Expenditures
MEPS-HC defines total expense as the sum of payments from all sources to hospitals, physicians, other health care providers (including dental care), and pharmacies for services reported by respondents in the MEPS-HC. Sources include direct payments from individuals and families, private insurance, Medicare, Medicaid, and miscellaneous other sources.

Type of service

Office-based: Includes expenses for visits to both physician and non-physician medical providers seen in office settings.
Hospital inpatient: Includes room and board and all hospital diagnostic and laboratory expenses associated with the basic facility charge, payments for separately billed physician inpatient services, and some emergency room expenses incurred immediately prior to inpatient stays.
Hospital outpatient: Includes expenses for visits to both physicians and other medical providers seen in hospital outpatient departments, including payments for services covered under the basic facility charge and those for separately billed physician services.
Emergency room: Includes payments for services covered under the basic facility charge and those for separately billed physician services, but excludes expenses for emergency room services that are included in a hospital inpatient admission.
Prescribed medicines: Includes expenses for all prescribed medications that were initially purchased or refilled during the year, as well as expenses for diabetic supplies.
Dental: Includes payments for services to any type of dental care provider, including general dentists, dental hygienists, dental technicians, dental surgeons, orthodontists, endodontists, and periodontists.
Ambulatory: Combines office-based, hospital outpatient, and emergency room expense categories described above.
Home health: Includes expenses for home care provided by agencies and independent providers.
Other: Includes expenses for care in all categories not specified as a separate category including those for miscellaneous medical equipment and supplies.

Age
Age was defined as age at the end of the year 2012.

Race/ethnicity
Classification by race and ethnicity was based on information reported for each family member. Respondents were asked if each family member's race was best described as American Indian, Alaska Native, Asian or Pacific Islander, black, white, or other. They also were asked if each family member's main national origin or ancestry was Puerto Rican; Cuban; Mexican, Mexicano, Mexican American, or Chicano; other Latin American; or other Spanish. All persons whose main national origin or ancestry was reported in one of these Hispanic groups, regardless of racial background, were classified as Hispanic. Since the Hispanic grouping can include black Hispanic, white Hispanic, Asian and Pacific Islanders Hispanic, and other Hispanic, the race categories of black, white, Asian and Pacific Islanders, and other only include non-Hispanics for the race/ethnicity classifications. MEPS respondents who reported other single or multiple races and were non-Hispanic were included in the other category. For this analysis, the following classification by race and ethnicity was used: Hispanic (of any race), non-Hispanic black single race, non-Hispanic white single race, and others, and non-Hispanic Asian and Pacific Islanders single race.

Health insurance status
Individuals under age 65 were classified into the following three insurance categories based on household responses to the health insurance status questions:

Any private health insurance: Individuals who, at any time during the year, had insurance that provided coverage for hospital and physician care (other than Medicare, Medicaid, or other public hospital/physician coverage) were classified as having private insurance. Coverage by TRICARE (Armed Forces-related coverage) was also included as private health insurance. Insurance that provided coverage for a single service only, such as dental or vision coverage, was not included.
Public coverage only: Individuals were considered to have public coverage only if they met both of the following criteria: 1) they were not covered by private insurance at any time during the year, and 2) they were covered by one of the following public programs at some point during the year: Medicare, Medicaid, or other public hospital/physician coverage.
Uninsured: The uninsured were defined as people not covered by private hospital/physician insurance, Medicare, TRICARE, Medicaid, or other public hospital/physician programs at any time during the entire year or their period of eligibility for the survey.

Income
Sample persons were classified according to the total yearly income of their family. Within a household, all people related by blood, marriage, or adoption were considered to be a family. Poverty status categories are defined by the ratio of family income to the Federal income thresholds, which control for family size and age of the head of family. Poverty status was based on annual income in 2012.

Poverty status categories are defined as follows:

Poor: Persons in families with income less than or equal to the poverty line; includes those who had negative income.
Near poor: Persons in families with income over the poverty line through 125 percent of the poverty line.
Low income: Persons in families with income over 125 percent through 200 percent of the poverty line.
Middle income: Persons in families with income over 200 percent through 400 percent of the poverty line.
High income: Persons in families with income over 400 percent of the poverty line.

About MEPS-HC

MEPS-HC is a nationally representative longitudinal survey that collects detailed information on health care utilization and expenditures, health insurance, and health status, as well as a wide variety of social, demographic, and economic characteristics for the U.S. civilian noninstitutionalized population. It is cosponsored by the Agency for Healthcare Research and Quality and the National Center for Health Statistics.

For more information about MEPS, call the MEPS information coordinator at AHRQ (301-427-1406) or visit the MEPS Web site at http://www.meps.ahrq.gov/.

References

Cohen, J. Design and Methods of the Medical Expenditure Panel Survey Household Component. MEPS Methodology Report No. 1. AHCPR Pub. No. 97-0026. Rockville, MD: Agency for Healthcare Policy and Research, 1997. http://meps.ahrq.gov/mepsweb/data_files/publications/mr1/mr1.shtml

Cohen, S. Design Strategies and Innovations in the Medical Expenditure Panel Survey. Medical Care, July 2003: 41(7) Supplement: III-5–III-12.

Cohen, S. and Uberoi, N. Differentials in the Concentration in the Level of Out-of-Pocket Health Expenditures across Population Subgroups in the U.S., 2011. Statistical Brief #423. September 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://meps.ahrq.gov/mepsweb/data_files/publications/st423/stat423.shtml

Cohen, S. and Yu, W. The Concentration and Persistence in the Level of Health Expenditures over Time: Estimates for the U.S. Population, 2008–2009. Statistical Brief #354. December 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.meps.ahrq.gov/mepsweb/data_files/publications/st354/stat354.shtml

Cohen, S. and Yu, W. The Concentration and Persistence in the Level of Health Expenditures over Time: Estimates for the U.S. Population, 2006–2007. Statistical Brief #278. March 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.meps.ahrq.gov/mepsweb/data_files/publications/st278/stat278.shtml

Ezzati-Rice, T.M., Rohde, F., Greenblatt, J. Sample Design of the Medical Expenditure Panel Survey Household Component, 1998–2007. Methodology Report No. 22. March 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.meps.ahrq.gov/mepsweb/data_files/publications/mr22/mr22.shtml

Suggested Citation

Cohen, S. Differentials in the Concentration in Out-of-Pocket Health Expenditures across Population Subgroups in the U.S., 2012. Statistical Brief #450. September 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://meps.ahrq.gov/mepsweb/data_files/publications/st450/stat450.shtml

* * *
AHRQ welcomes questions and comments from readers of this publication who are interested in obtaining more information about access, cost, use, financing, and quality of health care in the United States. We also invite you to tell us how you are using this Statistical Brief and other MEPS data and tools and to share suggestions on how MEPS products might be enhanced to further meet your needs. Please email us at MEPSProjectDirector@ahrq.hhs.gov or send a letter to the address below:

Steven B. Cohen, PhD, Director
Center for Financing, Access, and Cost Trends
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, MD 20850

Figure data for accessible table follows the image

Figure 1. Distribution of out-of-pocket health expenditures for the U.S. population by magnitude of out-of-pocket expenditure and mean out-of-pocket expenditures, 2012
	Out-of-pocket health expenditures	Out-of-pocket mean expenditures
Top 1%	20.5%	$12,500
Top 5%	45.1%	$5,501
Top 10%	61.3%	$3,741
Top 25%	85.0%	$2,072
Top 50%	97.8%	$1,192
Note: Total out-of-pocket expenditures = $191 billion Source: Center for Financing, Access, and Cost Trends, AHRQ, Household Component of the Medical Expenditure Panel Survey, 2012

Figure 2. Percentage of the U.S. population with out-of-pocket health care expenditures by age, 2012
	Total population	Ages 0-64	Age 65+
Greater than or equal to $2,000	7.2%	6.1%	14.0%
Greater than or equal to $5,000	1.5%	1.2%	3.7%
Greater than or equal to $10,000	0.4%	0.3%	1.0%
Source: Center for Financing, Access, and Cost Trends, AHRQ, Household Component of the Medical Expenditure Panel Survey, 2012

Figure 3. Percentage of health care expenditures by type of service, 2012
	Ambulatory	Hospital inpatient	RX	Dental	Home health	Other
All expenditures	100% ($483.7 billion)	100% ($409.1 billion)	100% ($293.0 billion)	100% ($84.8 billion)	100% ($54.9 billion)	100% ($25.3 billion)
Other sources of payment	87.7% ($424.2 billion)	96.1% ($393.1 billion)	80.8% ($236.9 billion)	51.5% ($43.7 billion)	91.1% ($50.0 billion)	46.4% ($11.7 billion)
Out-of-pocket payments	12.3% ($59.4 billion)	3.9% ($16.0 billion)	19.2% ($56.1 billion)	48.5% ($41.1 billion)	8.9% ($4.9 billion)	53.6% ($13.6 billion)
Note: Total expenditures = $1.35 trillion. Total OOP expenditures = $191 billion. Source: Center for Financing, Access, and Cost Trends, AHRQ, Household Component of the Medical Expenditure Panel Survey, 2012

Figure 4. Out-of-pocket expenditures by type of service, 2012
	Out-of-pocket expenditures (in billions)	Percentage
Ambulatory	$59.4	31.1%
Hospital inpatient	$16.0	8.4%
RX	$56.1	29.4%
Dental	$41.1	21.5%
Other (includes $4.9 B for home health)	$18.5	9.7%
Note: Total = $191 billion. Source: Center for Financing, Access, and Cost Trends, AHRQ, Household Component of the Medical Expenditure Panel Survey, 2012

Figure 5. Distribution of out-of-pocket health care expenditures and mean out-of-pocket expenditures for the U.S. population by age, 2012
	Ages 0-17	Ages 18-44	Ages 45-64	Age 65+
Figure 5a. Distribution of out-of-pocket health care expenditures for the U.S. population by age, 2012
Top 5%	60.5%	47.8%	38.2%	38.8%
Top 10%	76.2%	64.6%	53.0%	52.0%
Top 25%	93.1%	87.0%	77.7%	74.0%
Top 50%	99.7%	98.6%	94.6%	91.6%
Figure 5b. Annual mean out-of-pocket expenditures for the U.S. population by age, 2012
	Ages 0-17	Ages 18-44	Ages 45-64	Age 65+
Top 5%	$3,287	$3,977	$6,519	$9,274
Top 10%	$2,071	$2,688	$4,521	$6,242
Top 25%	$1,013	$1,448	$2,652	$3,544
Top 50%	$542	$820	$1,613	$2,191
Source: Center for Financing, Access, and Cost Trends, AHRQ, Household Component of the Medical Expenditure Panel Survey, 2012

Figure 6. Distribution of out-of-pocket health care expenditures and mean out-of-pocket expenditures for the U.S. population by race/ethnicity, 2012
	White, non-Hispanic	Black, non-Hispanic	Asian, non-Hispanic	Hispanic
Figure 6a. Distribution of out-of-pocket health care expenditures for the U.S. population by race/ethnicity, 2012
Top 5%	41.2%	56.1%	46.9%	57.0%
Top 10%	56.8%	71.1%	64.0%	73.3%
Top 25%	81.1%	90.8%	87.7%	92.7%
Top 50%	96.1%	99.4%	98.8%	99.9%
Figure 6b. Annual out-of-pocket mean expenditures for the U.S. population by race/ethnicity, 2012
	White, non-Hispanic	Black, non-Hispanic	Asian, non-Hispanic	Hispanic
Top 5%	$6,245	$4,039	$3,792	$3,179
Top 10%	$4,307	$2,562	$2,560	$2,044
Top 25%	$2,460	$1,307	$1,404	$1,035
Top 50%	$1,457	$716	$791	$557
Source: Center for Financing, Access, and Cost Trends, AHRQ, Household Component of the Medical Expenditure Panel Survey, 2012

Figure 7. Distribution of out-of-pocket health care expenditures and mean out-of-pocket expenditures for the U.S. population by sex, 2012
	Male	Female
Figure 7a. Distribution of out-of-pocket health care expenditures for the U.S. population by sex, 2012
Top 5%	47.0%	43.5%
Top 10%	64.1%	59.1%
Top 25%	87.2%	82.9%
Top 50%	98.6%	96.9%
Figure 7b. Annual mean out-of-pocket expenditures for the U.S. population by sex, 2012
	Male	Female
Top 5%	$4,901	$6,061
Top 10%	$3,335	$4,104
Top 25%	$1,815	$2,304
Top 50%	$1,026	$1,347
Source: Center for Financing, Access, and Cost Trends, AHRQ, Household Component of the Medical Expenditure Panel Survey, 2012

Figure 8. Distribution of out-of-pocket health care expenditures and mean out-of-pocket expenditures for the U.S. population under age 65 by insurance status, 2012
	Uninsured	Public Insurance	Private Insurance
Figure 8a. Distribution of out-of-pocket health care expenditures of the U.S. population under age 65 by insurance status, 2012
Top 5%	55.5%	68.1%	41.4%
Top 10%	73.2%	84.5%	57.6%
Top 25%	93.3%	97.8%	81.8%
Top 50%	100.0%	100.0%	96.1%
Figure 8b. Annual mean out-of-pocket expenditures of the U.S. population under age 65 by insurance status, 2012
	Uninsured	Public Insurance	Private Insurance
Top 5%	$5,087	$2,682	$5,068
Top 10%	$3,349	$1,658	$3,531
Top 25%	$1,705	$766	$2,001
Top 50%	$913	$392	$1,176
Source: Center for Financing, Access, and Cost Trends, AHRQ, Household Component of the Medical Expenditure Panel Survey, 2012

Figure 9. Distribution of out-of-pocket health care expenditures and mean out-of-pocket expenditures for the U.S. population by income, 2012
	Poor	Near poor	Low income	Middle income	High income
Figure 9a. Distribution of out-of-pocket health care expenditures for the U.S. population by income, 2012
Top 5%	61.2%	52.3%	48.3%	45.6%	38.9%
Top 10%	77.5%	68.6%	64.5%	61.3%	54.5%
Top 25%	95.2%	90.0%	87.8%	84.2%	79.3%
Top 50%	100.0%	99.4%	98.9%	97.3%	95.1%
Figure 9b. Annual mean out-of-pocket expenditures for the U.S. population by income, 2012
	Poor	Near poor	Low income	Middle income	High income
Top 5%	$3,979	$4,359	$4,590	$5,467	$6,383
Top 10%	$2,518	$2,826	$3,064	$3,669	$4,468
Top 25%	$1,238	$1,478	$1,671	$2,017	$2,603
Top 50%	$650	$816	$940	$1,165	$1,560
Source: Center for Financing, Access, and Cost Trends, AHRQ, Household Component of the Medical Expenditure Panel Survey, 2012

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STATISTICAL BRIEF #450: Differentials in the Concentration in Out-of-Pocket Health Expenditures across Population Subgroups in the U.S., 2012