Health Care Use and Decision-Making among Lower-Income Families in High-DeductibleHealth Plans

Abstract

Background:

Lower-income families may face unique challenges in high-deductible health plans (HDHPs).

Methods:

We administered a cross-sectional survey to a stratified random sample of families in a New England health plan’s HDHP with ≥$500 in annualized out-of-pocket expenditures. Lower-income families were defined as having incomes < 300% FPL. Primary outcomes were cost-related delayed or foregone care, difficulty understanding plans, unexpected costs, information-seeking, and likelihood of asking their physician about hypothetical recommended services subject to the plan deductible. Multivariatelogistic regression was used to control for potential confounders of associations between income group and primary outcomes.

Results:

Lower-income families (n = 141) were more likely than higher-income families (n = 273) to report cost-related delayed or foregone care (57% vs. 42%, adjusted odds ratio (AOR) 1.81 [95% CI, 1.15-2.83]). There were no differences in plan understanding, unexpected costs, or information-seeking by income. Lower-income families were more likely than others to say they would ask their physician about a $100 blood test (79% vs. 63%, AOR 1.97 [95% CI, 1.18-3.28]) or a $1000 screening colonoscopy (89% vs. 80%,AOR 2.04 [95% CI, 1.06-3.93]) subject to the plan deductible.

Conclusions:

Lower-income families with out-of-pocket expenditures in an HDHP were more likely than higher-income families to report cost-related delayed or foregone care but did not report more difficulty understanding or using their plans, and mightbe more likely to question services requiring out-of-pocket expenditures. Policymakers and physicians should consider focused monitoring and benefit design modifications to support lower-income families in HDHPs.

In the midst of the current economic downturn, many Americans are paying more for their health care.¹ One way in which a growing number of families are facing higher levels of cost-sharing for health care is enrollment in high-deductible health plans (HDHPs).² These plans, which feature annual deductibles of at least $1000per individual and at least $2000 per family before most services are covered, seek to encourage patients to become more cost-effective consumers of health care and frequently offer lower premiums than other types of health insurance.¹ In early 2009, 23% of all non-elderly adults with private insurance, and nearly 50% of adults who purchased coverage through the non-group market, were enrolled in an HDHP.² Becauseof their relatively low premiums, HDHPs are also playing a prominent role in expanding insurance coverage. For example, most individuals who have purchased unsubsidized plans through the Commonwealth Connector, the new health insurance exchange in Massachusetts, have selected products like HDHPs that offer low premiums with high levels of cost-sharing.³

Early enrollees in HDHPs tended to have higher incomes than enrollees in plans with low levels of cost-sharing.^4-6 Currently, however, lower-income individualswith private health insurance coverage are as likely to be enrolled in an HDHP as higher-income individuals.⁷ As enrollment in HDHPs has grown, many analysts have voiced concerns about how these plans may impact low-income families.^8-11 Decades of health services research has demonstrated that higher levels of cost-sharing reduce health care utilization, sometimes with greater adverse consequences for low-income patients.^12-15 Ideally, HDHPs could stimulate patients to become more sophisticated consumers, but people with low incomes have not demonstrated the same levels of engagement in managing their health care as those with higher incomes.¹⁶ By requiring patients to pay for selected services, HDHPs could stimulate more physician-patient communication about the value of recommended health care, but low-income patients are less likely to report their providers always explain things in a way they can understand.¹⁷

Despite these concerns, little is known about how the experiences of lower-income families in HDHPs compare with those of higher-income families. The impact of household income on health care use and decision-making may be particularly important for familieswho face out-of-pocket expenditures for care. In this study, we hypothesized that lower-income families with out-of-pocket expenditures in HDHPs would be more likely than higher-income families to delay or forego health care due to cost, report difficulties understanding their plans, exhibit low levels of information-seeking about plan coverage and service costs, and avoid talking with their physicians about services requiring out-of-pocket expenditures.

METHODS

The study population was drawn from enrollees in HDHPs of Harvard Pilgrim Health Care, a New England-based non-profit health insurer. In 2002, Harvard Pilgrim began offering health plans with annual deductibles of at least $1000 for individuals and $2000 forfamilies, the standard definition of an HDHP.¹ In these HDHPs, most preventive services including routine check-ups, immunizations, and selected screening tests wereexempt from the deductible (i.e., enrollees paid either a co-payment or nothing for these services, whether or not they had met the deductible amount). In contrast, most diagnostic laboratory and imaging tests were not covered until the deductible had been met.

Study Population

Our target population was families in HDHPs who had engaged with their health plans as evidenced by accrual of out-of-pocket health care expenditures during a defined time period. Accordingly, we specified the sample frame as adults 18 years of age and olderwho, as of November 2008, were subscribers enrolled in a Harvard Pilgrim Health Care HDHP with an individual deductible of at least $1000 and a family deductible of at least $2000 and had: (1) continuous enrollment in an HDHP for at least the previous 6 months; (2) at least 1 child < 18 years of age also enrolled in the plan; and (3) annualized family out-of-pocket costs (defined as outpatient visit and prescription drug co-pays) of at least $500 in an HDHP. For families enrolled in an HDHP for the previous 12 months, annualized out-of-pocket expenditures constituted their full observed out-of-pocket expenditures over this time period. For families enrolled in an HDHP for between 6 and 12 months, annualized out-of-pocket expenditures were calculated by doubling their last 6 months of observed out-of-pocket expenditures. This threshold of annualized out-of-pocket expenses included 54% of all families who met other inclusion criteria.

We oversampled households living in low-income areas by stratifying families that met our inclusion criteria into 2 groups based on address information from health plan records: (1) residence in a census block group with a median household income in the 0-25% quartile of the sample frame and (2) residence in a census block group with a median household income in the upper 3 quartiles of the sample frame. Random sampling was performed in each stratum until surveys from approximately 200 families in each group were completed.

Survey Administration

Surveys were mailed between January and March 2009. The cover letter asked the adult in the family who is responsible for the family’s health care decisions to complete the survey. We sent 2 mail waves followed by attempts at telephone administration.

Survey Design

The survey consisted of 22 items that collected data on health plan characteristics, attitudes towards health care utilization, unexpected costs, information-seeking behaviors, cost- related delayed or foregone care, and demographic characteristics. Survey domains and questions were developed based on a previous focus group study in this population¹⁸ and were in some cases drawn from existing national surveys. The draftsurvey underwent cognitive pre-testing and piloting with a total of 60 respondents. The study was approved by the Harvard Pilgrim Health Care Institutional Review Board.

Primary Outcome Variables

The primary outcome variables related to health care access were whether care was delayed or foregone due to cost for children, adults, or any family member in the previous 6 months. Primary outcome variables related to plan understanding and decision-makingincluded finding one’s HDHP difficult to understand; feeling not well protected fromout-of-pocket expenses; and encountering unexpected health care costs, ever trying to find out whether a service would be covered, or ever trying to find out how much one wouldhave to pay for a service since joining the HDHP.

In order to gauge respondents’ willingness to discuss health care services with their physicians, we presented 3 hypothetical scenarios that described a recommended service and stated the service would not be covered by their insurance plan. The serviceswere (1) a $100 blood test ordered as part of a routine check-up; (2) a $1000 colonoscopy to screen for colon cancer; and (3) a $2000 MRI for minor back pain symptoms. In each case, the primary outcome variable was whether respondents said they would be likely to ask their doctor to delay the test or make a different plan, due to the cost. Questions were worded to focus on whether cost, rather than other concerns, would prompt a discussion with the doctor.

Secondary Outcome Variables

Respondents from families with any delayed or foregone care in the previous 6 months were asked what types of services were delayed or foregone. Additionally, these respondents were asked whether the delayed or foregone care caused a loss of time at work, school, or other important life activities; a serious increase in the patient’s or family’s level of stress; a temporary disability that included a significant amount of pain and suffering; or a long-term disability.

Classification of Income Groups

Self-reported household income data were combined with health plan data on household size to calculate a percentage of the Federal Poverty Level (FPL) for each family. A dichotomous variable was constructed where “lower-income” was defined as less than 300% of the FPL and “higher-income” was defined as greater than or equal to 300% of the FPL. This break point between lower and higher incomes was chosen becauseof the policy relevance of this division as the threshold for where subsidies start for purchase of health plans through the Massachusetts Commonwealth Connector, and the distribution of percentage of FPL in the sample.

Covariates

Data on race; respondent education; chronic illness; plan choice; presence of a Health Savings Account (HSA), Health Reimbursement Account (HRA), Flexible Spending Account (FSA), or Medical Savings Account (MSA); and employer reimbursement for out-of-pocket costs outside of a special savings account were obtained from the survey. Race and education data were collected using categories similar to those used in the Census. Race was operationalized as a dichotomous variable where self-identification as any race other than White was considered minority status. Education was operationalized as a dichotomous variable based on whether the survey respondent reported having a college degree. Plan choice was defined as respondent report of having a choice of more than one health plan through the respondent’s employer, spouse or partner. Chronic illness was defined as a condition that has lasted or is expected to last a year or longer, may limit what one can do, and may require ongoing care. Data on household size, child age, adult age, individual and family deductible amounts, and out-of-pocket costs were obtained from health plan records. Out-of-pocket costs were obtained from health plan data and represent the sum of progress towards the deductible, co-payments, and co-insurance charges in the last 6 months.

Data Analysis

All primary and secondary outcome variables were specified a priori. We compared the characteristics and survey responses of families in the 2 income groups using continuity-adjusted chi-square tests and the Wilcoxon rank-sum test with a pre-specified α = .05. For primary outcomes that were associated with income group in bivariate analyses, we estimated logistic regression models to control for potential confounders. Model covariates were selected based on an a priori set of predisposing, enabling, and need factors related to health care utilization.¹⁹ We evaluated model covariates for pairwise interactions and found none to be statistically significant. All analyses were performed using SAS, version 9.1 (SAS Institute, Cary, North Carolina).

RESULTS

Surveys were mailed to 750 out of 2635 eligible families, and 434 surveys were completed by either mail or phone. The response rate was 55% in the lower block group median household income stratum and 61% in the higher block group median household income stratum. There were no statistically significant differences between respondents and non-respondents in block group median household income stratum, health plan characteristics, mean out-of-pocket costs, mean household size, or the family's mean adult or child age.

Twenty families had missing household income data and were excluded from analyses.There were no statistically significant differences in household size, adult or child age, race/ethnicity, educational level, prevalence of chronic illness, health plan characteristics, or mean out-of-pocket costs between families who reported household income andfamilies with missing income data.

Demographic Characteristics

Compared with higher-income families, families with lower incomes were more likelyto live in a low-income census block group (61.0% vs. 41.8%, P< .001) and be minorities (8.5% vs. 2.9%, P = .02), were larger (4.2 vs. 3.9 individuals, P = .01), and were less likely to have an adult survey respondent with a college degree (26.2% vs. 56.0%, P < .001) (Table 1). Approximately 80% of families in each income group had at least 1 family member with a chronic condition. Seventy-two percent of families were from New Hampshire and 28% were from Massachusetts.

Table 1.

Characteristics of Participant Families by Household Income

	Families with FPL < 300%a (n = 141)	Families with FPL > 300% (n = 273)	P Value
Demographic characteristics
Residence in low-income census block group, %b	61.0	41.8	<.001
Mean household size, n	4.2	3.9	.01
Mean child age, y	9.9	9.8	.81
Mean adult age, y	37.5	40.2	<.001
Minority, %c	8.5	2.9	.02
Mean annual income, $	44 734	86 603	<.001
Respondent with college degree, %	26.2	56.0	<.001
Any chronic illness in family, %d	82.9	79.1	.44
Health plan characteristics
Family had a choice of other health plans, %e	42.6	44.6	.76
Mean annual individual deductible, $	1291	1288	.94
Mean annual family deductible, $	3443	3489	.67
HSA, HRA, FSA or MSA, %	26.6	34.8	.12
Employer reimburses OOP costs, %f	7.1	16.7	.01
Mean annual employer OOP cost reimbursement, $g	1250	1066	.72
Any OOP cost reimbursement mechanism, %h	30.2	44.7	.01
Mean OOP costs in last 6 months, $i	1253	1218	.74

Abbreviations: FPL, Federal Poverty Level; FSA, Flexible Spending Account; HRA, Health Reimbursement Account; HSA, Health Savings Account; MSA, Medical Savings Account; OOP, out-of-pocket

^aFPL calculated using 2008 Department of Health and Human Services Poverty Guidelines.

^bCensus block group with a median household income in the lowest quartile in the initial sample frame.

^cSelf-identification as any race other than White.

^dAny condition that has lasted or is expected to last a year or longer, may limit what one can do, and may require ongoing care.

^eChoice of more than one health benefit plan through the respondent's employer, spouse or partner.

^fAny employer reimbursement for OOP costs outside of an HSA, HRA, FSA or MSA.

^gAmong families with employer reimbursement for OOP costs outside of an HSA, HRA, FSA or MSA.

^hAny HSA, HRA, FSA, MSA, or other employer reimbursement.

ⁱHealth plan data on progress towards deductible, co-payments, and co-insurance charges.

Health Plan Characteristics

The vast majority of families (93%) were enrolled in a health maintenance organization HDHP (i.e., a plan that became a health maintenance organization after the deductible was exceeded). There were no statistically significant differences between the 2 income groups in mean individual deductible, mean family deductible, or mean out-of-pocket costs in the previous 6 months. Most families (56%) reported that their family did not have a choice of more than 1 health insurance plan, and there were no statistically significant differences in degree of plan choice by income group. Only a minority of families (32%) reported having a special account for health care expenses such as an HSA, HRA, FSA or MSA, and there were no statistically significant differences in the proportion of families in each income group who reported having such an account. However, significantlymore respondents in the higher-income group (16.7% vs. 7.1%, P = .01) reported that their employer provided reimbursement (outside of a special account) for some out-of-pocket health care expenses. Overall, higher-income families were more likely to have either a special account or employer reimbursement for out-of-pocket expenses (44.7% vs. 30.2%, P = .01).

Delayed or Foregone Care Due to Cost

Lower-income families were significantly more likely than higher-income families to report having cost-related delayed or foregone care for any adult (51.1% vs. 34.8%, P = .01) or child (24.1% vs. 13.9%, P = .01) in the previous 6 months (Table2). Controlling for covariates (Table 3), lower-income families had nearly twice the odds of any cost-related delayed or foregone care in the last 6 months (AOR 1.81 [95% CI, 1.15-2.83]). Other factors significantly associated with having cost-related delayed or foregone care were having a family member with a chronic illness (AOR 1.79 [95% CI, 1.05-3.06]) and having had a choice of health plans (AOR 1.57 [95% CI, 1.04-2.35]).

Table 3.

Factors Predicting Family Delayed or Foregone Care Due to Cost in Previous 6 Months

Predictor	AOR (95% CI)a
Federal Poverty Level < 300%	1.81 (1.15-2.83)
No college degreeb	1.30(0.84-2.00)
Chronic illnessc	1.79 (1.05-3.06)
Choice of health plansc	1.57 (1.04-2.35)
Out-of-pocket cost reimbursemente	1.17 (0.76-1.79)

Abbreviations: AOR, adjusted odds ratio; CI, confidence interval

^aAdjusted for adult age, child age, household size, individual deductible and family deductible.

^bRespondent with less than a college education.

^cAny adult or child chronic illness in family.

^cchoice of more than one health benefit plan through the respondent's employer, spouse or partner.

^eHealth Savings Account, Health Reimbursement Account, Flexible Spending Account, Medical Savings Account, or employer out-of-pocket cost reimbursement.

Compared with higher-income families, lower-income families were significantly more likely to report having delayed or foregone operations or procedures due to cost (19.8% vs. 6.0%, P = .01). Respondents from lower-income families, compared with respondents from higher-income families, reported higher rates of increased stress, loss of time at work or school, temporary disability, and long-term disability as a consequence of cost-related delayed or foregone care, but these differences were not statistically significant.

Plan Use and Information-Seeking

Respondents from lower-income families were no more likely than those from higher-income families to find their health plan difficult to understand, or feel their family was not well protected from out-of-pocket health care expenses (Table 4). Additionally, respondents from lower-income families were no less likely than respondents from higher-income families to report having tried to find out in advance whether they would have topay for a specific service before meeting their deductible limit, or how much they wouldhave to pay for a service since joining their health plan.

Table 4.

Health Care Decision-Making Attitudes and Behaviors by Household Income

	Families with FPL < 300% (n = 141)	Families with FPL ≥ 300% (n = 273)	P Value
Plan use and information-seeking, %
Feels unprotected from OOP expensesa	54.3	44.1	.06
Finds current health plan difficult to understandb	24.8	26.2	.85
Ever encountered unexpected costs in current plan	46.4	40.7	.32
Ever tried to find out whether would have to pay for a service before meeting deductible in current plan	50.7	52.4	.83
Ever tried to find out how much would need to pay for a service in current plan	39.3	40.9	.84
Discussing hypothetical recommended services not covered by HDHP, %c
Likely to discuss $100 routine blood test	79.4	63.1	.01
Likely to discuss $1000 screening colonoscopy	89.4	80.2	.02
Likely to discuss $2000 MRI for low back pain	94.3	90.4	.24

Abbreviations: FPL, Federal Poverty Level; HDHP, high-deductible health plan; MRI, magnetic resonance imaging; OOP, out-of-pocket

^aRespondent feels self and family “not very well” or “not at all” protected from OOP expenses.

^bRespondent finds current health insurance plan “somewhat difiicult” or “very difficult” to understand.

^cRespondents were asked how likely they would be to ask their doctor whether they could delay or modify, due to cost, 3 hypothetically recommended services they knew would not be covered by their health insurance: (1) $100 routine blood test, (2) $1000 screening colonoscopy, and (3) $2000 MRI for minor back pain symptoms.

Engaging Physicians in Conversations about Health Care Services

Most respondents in each income group reported they would be likely to talk with their physicians about delaying or making a different plan for each of the 3 hypotheticalservices due to cost (Table 4). After controlling for covariates (Table 5), lower-incomefamilies had approximately twice the odds of being likely to discuss a hypothetical $100blood test (AOR 1.97 [95% CI, 1.18 to 3.28]) or a $1000 screening colonoscopy (AOR 2.04 [95% CI, 1.06 to 3.93]) subject to the plan deductible.

Table 5.

Factors Predicting Likelihood of Discussing Hypothetical Recommended Services Subject to Plan Deductible

	$100 blood test	$1000 colonoscopy	$2000 MRI
Predictor	AOR (95% CI)a	AOR (95% CI)a	AOR (95% CI)a
FPL < 300%	1.97 (1.18-3.28)	2.04 (1.06-3.93)	1.98 (0.82-4.78)
No college degreeb	1.35 (0.85-2.14)	1.95 (1.09-3.48)	1.02 (0.46-2.26)
Chronic illnessc	1.08 (0.62-1.89)	0.72 (0.35-1.48)	0.96 (0.36-2.53)
Choice of health plansd	1.09 (0.70-1.69)	1.22 (0.71-2.10)	3.26 (1.37-7.74)
OOP cost reimbursemente	0.81 (0.52-1.27)	1.55 (0.88-2.73)	1.14 (0.53-2.44)

Abbreviations: AOR, adjusted odds ratio; CI, confidence interval; FPL, Federal Poverty Level; OOP, out-of-pocket

^aAdjusted for child average age, adult average age, household size, individual deductible, and family deductible.

^bRespondent with less than a college education.

^cAny adult or child chronic illness in family.

^dchoice of more than one health benefit plan through the respondent's employer, spouse or partner.

^eHealth Savings Account, Health Reimbursement Account, Flexible Spending Account, Medical Savings Account, or employer out-of-pocket cost reimbursement.

COMMENT

We found that lower-income families with at least $500 in annualized out-of-pocketexpenditures in an HDHP were more likely than higher-income families to delay or forego health care services due to cost. However, respondents from lower-income families were no more likely to report difficulty understanding and using their health plans, and might be more likely to question the value of services requiring out-of-pocket expenditures.While a variety of studies have examined the effects of cost-sharing on low-income individuals in private and public health insurance plans,¹² this is one of the fewstudies to examine the relationship between self-reported income and experiences in a high-deductible health plan.

Overall we observed relatively high rates of delayed or foregone care in both income groups, with nearly half of all families having either delayed or foregone care in the last 6 months due to the cost. These rates were substantially higher than the 20% of the U.S. population reporting either unmet need or delayed care in the previous 12 monthsin the 2007 Heath Tracking Household Survey.²⁰ It is unclear whether this difference primarily reflects the impact of higher cost-sharing levels on our sample population or our inclusion of only families that had accumulated ≥ $500 in annualized out-of-pocket expenditures.

Respondents in both groups felt they had a good understanding of how their HDHP worked, though they reported low levels of information-seeking about their benefits and out-of- pocket costs for services. Importantly, we did not detect any differences in information-seeking between lower and higher-income families. The low overall rate of information-seeking was somewhat surprising considering this group of families had both a high level of need for care, as manifested by a high burden of chronic illness, and evidence of health care utilization, as manifested by at least $500 in annualized out-of-pocket expenditures. It is possible that many of these families had become so familiar with their plans from having had high out-of-pocket costs that they felt little need to gather additional information. The fact that many families reported delaying or foregoing preventive care, however, suggests there could have been some confusion at least about deductible exemptions, as most preventive services were exempt from most families’ deductibles.

The vast majority of respondents indicated they would be likely to ask their doctor about delaying a hypothetical service not covered by their health plan, or making a different plan due to the cost. Contrary to our initial hypothesis, respondents from lower-income families voiced an even greater desire than those from higher-income families totalk with their physicians about 2 of 3 hypothetical services. These findings suggest physicians have a central role to play in helping their patients navigate the challenges of decision-making in HDHPs. Physician guidance around decision-making could be particularly helpful for lower-income families in HDHPs who may be more likely to delay or go without care because of cost. The capacity of physicians to assume this role, however, is currently limited by time²¹ and lack of knowledge about both HDHPs²² and the costs of services.²³ These barriers could potentially be surmountedthrough electronic medical record tools that could provide physicians with brief, actionable information to encourage shared decision-making processes that consider out-of-pocket costs.

Beyond the implications for clinicians, our findings have important implications for federal health reform. Reform legislation that establishes an individual health insurance mandate could lead more families to enroll in plans with high levels of cost-sharing, as has been seen following the implementation of coverage mandates in Massachusetts.³ If more families do enroll in HDHPs, policymakers should consider strategiesto support patients facing high levels of cost-sharing. Based on our finding that lower-income families in HDHPs were more likely than higher-income families to delay or foregohealth care due to cost, policymakers could consider reducing deductibles for lower-income families, limiting deductibles to a proportion of a family’s income, or providingincome-based cost-sharing subsidies.²⁴ Given that so many respondents in our sample would ask their doctor about delaying a hypothetical service not covered by theirplan, both physicians and patients need more reliable information on the price and valueof services in order to fully engage in shared decision-making about costly medical care. Finally, our finding that many families had delayed or gone without screening tests, immunizations or outpatient health maintenance visits due to cost suggests benefits need to be both effectively designed and conveyed to encourage use of clinical preventive services.²⁵

Our study has several limitations. First, these are self-reported, cross-sectionaldata subject to recall bias. If families with lower incomes had more memorable experiences with cost-related delayed or foregone care, for example, they could potentially better recall delayed or foregone care than higher-income families. Second, these data may not be representative of all other HDHP populations. Our sample was limited to enrollees in 1 New England health plan, included families with relatively high burdens of chronic illnesses, and contained few racial and ethnic minorities. Further, our inclusion criterion of at least $500 in annualized outpatient visit and prescription drug co-payments mayhave excluded families who faced access barriers so significant that they never reached this level of spending, and makes our findings less generalizable to families with lowerlevels of out-of-pocket expenses. Third, as in other studies of HDHPs, families who choose these plans may differ in important and often unobservable ways from those who do not, though most families in our sample reported having no choice of another health plan. Fourth, our measures gauging respondents’ willingness to discuss hypothetical recommended services may not be completely predictive of their actual behavior. Finally, the lack of a non-HDHP comparison group limits the degree to which our observed income group differences and similarities can be contrasted with health plans that have small or no deductibles.

Our study adds new findings on the experiences of lower-income families in HDHPs. We found that among HDHP enrollees with out-of-pocket expenditures, lower-income families were more likely than higher-income families to delay or forego health care services due to cost. However, they were no more likely to report difficulty understanding and using their health plans and might be more likely to question the value of services requiring out-of-pocket expenditures. More research is needed to further describe the effects of HDHPs on low-income families, as well as evaluate how benefit design modifications andtargeted decision tools can overcome challenges faced by patients in these plans.

Table 2.

Delayed or Foregone Care Due to Cost in Previous 6 Months by Household Income

	Families with FPL < 300% (n = 141)	Families with FPL > 300% (n = 273)	P Value
Delayed or foregone care in last 6 months, %
Any delayed or foregone pediatric care	24.1	13.9	.01
Any delayed or foregone adult care	51.1	34.8	.01
Any delayed or foregone care in family	57.4	42.5	.01
Types of delayed or foregone care, %a
Emergency department visit	60.5	54.3	.47
Preventive careb	32.1	19.8	.07
Imaging test	24.7	23.3	.95
Prescription medication	21.0	16.4	.52
Specialist visit	22.2	13.8	.18
Laboratory test	14.8	9.5	.36
Operation or procedure	19.8	6.0	.01
Physical therapy	13.6	11.2	.78
Consequences of delayed or foregone care, %c
Caused significant long-term disability	3.7	0.9	.38
Caused significant temporary disability	21.0	14.7	.33
Caused significant loss of time at work or school	18.5	10.3	.15
Caused serious increase in stress	34.6	31.0	.71

Abbreviations: FPL, Federal Poverty Level

^aAmong families with any cost-related delayed or foregone care in the previous 6 months. Services listed were the most common delayed or foregone services in this sample.

^bScreening test (e.g., mammography or colonoscopy), immunization, or outpatient visit for a “routine check-up.”

^cAmong families with any cost-related delayed or foregone care in the previous 6 months. The denominators were 81 among families with FPL < 300% and 116 among families with FPL > 300%.