Indicator: Total Out-of-Pocket Cost
Subcategory: Total Out-of-Pocket Cost (Individuals) and Total Out-of-Pocket Cost (Families)
Indicator Description: “Out-of-pocket costs” (Families) include family expenses for premiums, copays, deductibles, and co-insurance for services and prescription drugs. They do not include over-the-counter medications. (Sometimes the definition of “out-of-pocket” spending excludes premiums.) “Family” is defined as the health insurance unit, which includes one or more individuals in a household who would likely be considered a family unit in determining eligibility for private or public coverage
Health care expenditures include:
● Premium costs – the amount health insurance companies change each month for coverage. Note that this metric includes premiums, while most other measures of out-of-pocket costs do not.
● Out-of-pocket costs
◦ Copayment – set dollar amount for covered services (i.e. $20 for general physician visit)
◦ Coinsurance – a percentage of the allowed cost of covered services (i.e. 20% of the allowed cost for a specialist visit)
◦ Deductible – set dollar amount that patients must pay out-of-pocket before their plan starts to cover the service (i.e. $200 drug deductible before drug coverage begins)
“Out-of-pocket costs” (Individuals) include expenses for copays, deductibles, and co-insurance for services and prescription drugs. They do not include premiums or over-the-counter medications. This differs from “Out-of-pocket costs” (Families) which include premiums, so the two should not be compared against each other.
Data Limitations: Federal Poverty Guidelines are issued by the Department of Health and Human Services each year and used to determine financial eligibility for certain federal programs. Beginning with the 2013 Current Population Survey, the health insurance coverage question series was re-designed and new questions were added. Due to these changes, users should be cautious when comparing Current Population Survey estimates from 2013 and forward with estimates from 2012 and earlier.
Indicator Source: California Health Care Foundation (CHCF): State Health Access Data Assistance Center (SHADAC) analysis of the Current Population Survey’s Annual Social and Economic Supplements.
Indicator Calculation Methodology: Indicator replicated from CHCF ACA411: Median Annual Out-of-Pocket Spending per Family. More information about out-of-pocket costs is available from CHCF, available at http://www.chcf.org/aca-411/explore-the-data#trend%2Caffordability%2Cfinancialburden%2Cfmoop%2CSymbolDollar%20(Total)%2C2013
Data Collection Methodology: ACA 411: Tracking Health Reform in California uses an interactive tool that provides baseline and trend data for selected measures to help answer how the Affordable Care Act (ACA) is changing insurance coverage, access to health care, and affordability in California. The data include uninsured rates, private and public coverage levels, insurance status, and Covered California enrollment; use of services and barriers to care; and consumer spending and premium sharing for employees, including low-wage, part-time, and temporary workers.