The Effects of Household Medical Expenditures on Income Inequality in the United States

A Review of the Public Health Literature Examining the Roles of Socioeconomic Status and Race/Ethnicity on Health Outcomes in the United States

This review of reviews examines the role of socioeconomic status (SES) indicators on health inequities among different racial and ethnic groups in the United States (US) between 2019 and 2023. Of the 419 articles, 27 reviews met the inclusion criteria and were aggregated into seven categories: COVID-19 and respiratory pandemic disparities; neighborhoods, gentrification, and food environment; surgical treatments; mental, psychological, and behavioral health; insurance, access to care, and policy impact; cancers; and other topics. The findings revealed a documented impact of SES indicators on racial/ethnic health inequities, with racial/ethnic minority communities, especially Black Americans, consistently showing poor health outcomes associated with lower SES, regardless of the outcome or indicator examined. These findings call attention to the importance of policies and practices that address socioeconomic factors and systemic racial/ethnic inequities affecting the social determinants of health affecting racial/ethnic inequities to improve health outcomes in the US population.

Does rural transformation affect rural income inequality? Insights from cross-district panel data analysis in Bangladesh

Rural transformation plays a crucial role in enhancing the income and employment prospects of the rural labor force. We investigate the effects of rural transformation on rural income inequality at the district level in Bangladesh using data from five years of nationally representative Household Income and Expenditure Surveys. The Gini coefficient is used to measure rural income inequality. In contrast, the share of high-value agricultural outputs and the share of rural non-farm employment are used as indicators of rural transformation. We find that rural income inequality is positively associated with the share of high-value agricultural outputs and the share of rural non-farm employment. The non-linear regression result shows an inverted U-shaped relationship between rural transformation and income inequality, which indicates that income inequality initially increases with rural transformation but decreases in the long run. Additionally, we find that rural income inequality is positively correlated with the proportion of household education expenditures, agricultural rental activity, and the share of remittances. This study also reveals that income inequality in rural areas of Bangladesh has a significant negative correlation with the government's social safety net program.

Employer-Sponsored Health Insurance Premium Cost Growth and Its Association With Earnings Inequality Among US Families

Importance

Costs of employer-sponsored health care benefits have increased faster than workers' wages for several decades, with important implications for disparities in earnings and wage stagnation.

Objective

To quantify how growth in employer-sponsored health insurance (ESI) premiums may have been associated with reduced annual wages, disparities in earnings by race and ethnicity and wage level, and wage stagnation among US families with ESI.

Design, Setting, and Participants

In this economic evaluation, serial cross-sectional analyses were performed of US families receiving ESI from 1988 to 2019 based on data from the Consumer Expenditure Survey, Kaiser Employer Health Benefits Survey, US Census Bureau's Current Population Survey, and federal payroll taxation rates. Statistical analysis was conducted from February 2022 to July 2023.

Main Outcomes and Measures

Percentage of annual compensation associated with health care premiums (after accounting for tax deductibility) and lost wages associated with growth in cost of premiums from 1989 to 2019 based on 1988 compensation. To assess disparities, analyses were stratified by race and ethnicity and wage level.

Results

In 1988, 44.7 million individuals (head of household: mean [SD] age, 43.3 [13.1] years; 30.1% were female; and 2.4% identified as Asian, 6.2% as Hispanic, 8.6% as non-Hispanic Black, and 82.8% as non-Hispanic White) were covered by ESI family plans; this number remained similar in 2019 at 44.8 million individuals (head of household: mean [SD] age, 47.1 [12.9] years; 41.3% were female; and 1.3% identified as Asian, 9.9% as Hispanic, 9.9% as non-Hispanic Black, and 78.9% as non-Hispanic White). In 1988, the mean (SD) household size was 3.3 (1.3) people, and in 2019, it was 3.4 (1.3) people. If ESI costs had remained at the same proportion of the 1988 average compensation package, then in 2019, the median US family with ESI could have earned $8774 (95% CI, $8354-$9195) more in annual wages. During all 32 years, health care premiums as a percentage of compensation were greater for non-Hispanic Black and Hispanic families than for non-Hispanic White families. By 2019, 13.8% (95% CI, 13.5%-14.1%) of compensation among non-Hispanic White families with ESI went to premium costs compared with 19.2% (95% CI, 18.8%-19.7%) among non-Hispanic Black families and 19.8% (19.3%-20.3%) among Hispanic families with ESI. In 2019, health care premiums as a percentage of compensation at the 95th percentile of earnings for families with ESI were 3.9% (95% CI, 3.8%-4.0%) compared with 28.5% (95% CI, 27.8%-29.2%) at the 20th percentile of earnings. From 1988 to 2019, the mean cumulative lost earnings associated with growth in health care premiums for the median US family with ESI was $125 340 (95% CI, $120 155-$130 525) in 2019 dollars, 4.7% of earnings over the 32-year period.

Conclusions and Relevance

This economic evaluation of US families receiving ESI suggests that 3 decades of increasing health care premiums were likely associated with reduced annual earnings and increased earnings inequality by race and ethnicity and wage level and were meaningfully associated with wage stagnation.

Out-of-Pocket Medical Expenditures in the Redesigned Current Population Survey: Evaluating Improvements to Data Processing

Household surveys are an important source of information on medical spending and burden. We examine how recently implemented post-processing improvements to the Current Population Survey Annual Social and Economic Supplement (CPS ASEC) affected estimates of medical expenditures and medical burden. The revised data extraction and imputation procedures mark the second stage of the CPS ASEC redesign and the beginning of a new time series for studying household medical expenditures. Using data for the calendar year 2017, we find that median family medical expenditures are not statistically different from legacy methods; however, updated processing does significantly reduce the percentage of families estimated to have a high medical burden (medical expenses are at least 10% of family income). The updated processing system also changes the characteristics of families with high medical spending and is primarily driven by changes in imputation of health insurance and medical spending.

Emerging NK cell therapies for cancer and the promise of next generation engineering of iPSC-derived NK cells

Adoptive cell therapy is a rapidly advancing approach to cancer immunotherapy that seeks to facilitate antitumor responses by introducing potent effector cells into the tumor microenvironment. Expanded autologous T cells, particularly T cells with engineered T cell receptors (TCR) and chimeric antigen receptor-T cells have had success in various hematologic malignancies but have faced challenges when applied to solid tumors. As a result, other immune subpopulations may provide valuable and orthogonal options for treatment. Natural killer (NK) cells offer the possibility of significant tumor clearance and recruitment of additional immune subpopulations without the need for prior antigen presentation like in T or B cells that could require removal of endogenous antigen specificity mediated via the T cell receptor (TCR and/or the B ecll receptor (BCR). In recent years, NK cells have been demonstrated to be increasingly important players in the immune response against cancer. Here, we review multiple avenues for allogeneic NK cell therapy, including derivation of NK cells from peripheral blood or umbilical cord blood, the NK-92 immortalized cell line, and induced pluripotent stem cells (iPSCs). We also describe the potential of engineering iPSC-derived NK cells and the utility of this platform. Finally, we consider the benefits and drawbacks of each approach and discuss recent developments in the manufacturing and genetic or metabolic engineering of NK cells to have robust and prolonged antitumor responses in preclinical and clinical settings.

Medical Crowdfunding and Disparities in Health Care Access in the United States, 2016‒2020

Objectives. To assess whether medical crowdfunding use and outcomes are aligned with health financing needs in the United States. Methods. We collected data on 437 596 US medical GoFundMe campaigns between 2016 and 2020. In addition to summarizing trends in campaign initiation and earnings, we used state- and county-level data to assess whether crowdfunding usage and earnings were higher in areas with greater medical debt, uninsured populations, and poverty. Results. Campaigns raised more than $2 billion from 21.7 million donations between 2016 and 2020. Returns were highly unequal, and success was low, especially in 2020: only 12% of campaigns met their goals, and 16% received no donations at all. Campaigns in 2020 raised substantially less money in areas with more medical debt, higher uninsurance rates, and lower incomes. Conclusions. Despite its popularity and portrayals as an ad-hoc safety net, medical crowdfunding is misaligned with key indicators of health financing needs in the United States. It is best positioned to help in populations that need it the least. (Am J Public Health. 2022;112(3):491-498. https://doi.org/10.2105/AJPH.2021.306617).

Chronic diseases: An added burden to income and expenses of chronically-ill people in Sri Lanka

In the global context, health and the quality of life of people are adversely affected by either one or more types of chronic diseases. This paper investigates the differences in the level of income and expenditure between chronically-ill people and non-chronic population. Data were gathered from a national level survey conducted namely, the Household Income and Expenditure Survey (HIES) by the Department of Census and Statistics (DCS) of Sri Lanka. These data were statistically analysed with one-way and two-way ANOVA, to identify the factors that cause the differences among different groups. For the first time, this study makes an attempt using survey data, to examine the differences in the level of income and expenditure among chronically-ill people in Sri Lanka. Accordingly, the study discovered that married females who do not engage in any type of economic activity (being unemployed due to the disability associated with the respective chronic illness), in the age category of 40-65, having an educational level of tertiary education or below and living in the urban sector have a higher likelihood of suffering from chronic diseases. If workforce population is compelled to lose jobs, it can lead to income insecurity and impair their quality of lives. Under above findings, it is reasonable to assume that most health care expenses are out of pocket. Furthermore, the study infers that chronic illnesses have a statistically proven significant differences towards the income and expenditure level. This has caused due to the interaction of demographic and socio-economic characteristics associated with chronic illnesses. Considering private-public sector partnerships that enable affordable access to health care services for all as well as implementation of commercial insurance and community-based mutual services that help ease burden to the public, are vital when formulating effective policies and strategies related to the healthcare sector. Sri Lanka is making strong efforts to support its healthcare sector and public, which was affected by the coronavirus (COVID-19) in early 2020. Therefore, findings of this paper will be useful to gain insights on the differences of chronic illnesses towards the income and expenditure of chronically-ill patients in Sri Lanka.

Do chronic illnesses and poverty go hand in hand?

In the global context, the health and quality of life of people are adversely affected by either one or more types of chronic diseases. The chronic pain associated with diagnosed patients may include heavy medical expenditure along with the physical and mental suffering they undergo. Usually, unbearable amounts of medical expenses are incurred, to improve or sustain the health condition of the patient. Consequently, the heavy financial burden tends to push households from a comfortable or secure life, or even from bad to worse, towards the probability of becoming poor. Hence, this study is conducted to identify the impact chronic illnesses have on poverty using data from a national survey referred as the Household Income and Expenditure Survey (HIES), with data gathered by the Department of Census and Statistics (DCS) of Sri Lanka in 2016. As such, this study is the first of its kind in Sri Lanka, declaring the originality of the study based on data collected from the local arena. Accordingly, the study discovered that married females who do not engage in any type of economic activity, in the age category of 40-65, having an educational level of tertiary level or below and living in the urban sector have a higher likelihood of suffering from chronic diseases. Moreover, it was inferred that, if a person is deprived from access to basic education in the level of education, lives in the rural or estate sector, or suffers from a brain disease, cancer, heart disease or kidney disease, he is highly likely to be poor. Some insights concluded from this Sri Lankan case study can also be applied in the context of other developing countries, to minimise chronic illnesses and thereby the probability of falling into poverty.

Economic costs of Chagas disease in Colombia in 2017: A social perspective

OBJECTIVE

To quantify the costs of Chagas disease in Colombia from a societal perspective in 2017.

METHODS

A cost-of-illness analysis was carried out using a prevalence-based approach. Costs attributable to Chagas were estimated from a bottom-up strategy, using population attributable fractions. Indirect costs were calculated using the human capital approach.

RESULTS

The estimated total cost of diagnosed Chagas disease was US $13.1 million and included $5.7 million in direct medical costs, $1.5 million in direct nonmedical costs, and $5.8 million in indirect costs: absenteeism ($2.2 million), presenteeism ($3.1 million), and premature deaths ($515228). On average, people diagnosed with Chagas disease incurred $594 in medical expenses, and more than half of that expense was directly attributable to Chagas. The annual cost to society for a person with chronic Chagas disease was $4226.

CONCLUSIONS

Chagas disease imposes a substantial financial burden on healthcare system and society. Economic cost of illness-related productivity losses is much more significant. Our research suggests that a health policy framework addressing as many of the social determinants of health as possible may be pivotal in containing social costs. Therefore, reducing this burden is not only the responsibility of the health system.

Impacto Económico de la Medicina Familiar en los Sistemas de Salud de Iberoamérica

Son escasos los estudios que abordan la importancia, económica y sanitaria, que tiene el modelo organizativo de un nivel asistencial o la presencia de determinados profesionales. El objetivo del presente estudio, de carácter descriptivo y transversal, fue explorar y analizar las posibles asociaciones entre la especialidad de medicina familiar e indicadores económicos y sanitarios em 16 países de Iberoamérica. El procesamiento de datos fue realizado a través del programa R, um lenguaje de programación que muestra “un conjunto de funciones que mantiene algún tipo de relación entre ellas”. Se observa una asociación en positivo, del número de especialistas de medicina familiar con el PIB, la inversión en salud y la esperanza de vida y en negativo con el índice GINI, la anemia, la mortalidad en menores de 5 años, la razón de mortalidad materna y la mortalidad en acidentes en tránsito. El PIB per cápita se relaciona negativamente con la anemia, la mortalidad en menores de 5 años, razón de mortalidad materna y por accidentes y menos intensamente con la mortalidade cardiovascular y el suicidio. No se observan correlaciones con el gasto de bolsillo o la inversión em sanidad. A pesar de las diferentes realidades socio sanitarias de los países estudiados se objetiva uma relación favorable entre la disponibilidad de especialistas en Medicina Familiar y mejores resultados en salud lo que sugiere que puede ser una estrategia eficiente para los servicios sanitarios. Son necesarios más estudios que analicen el alcance estadístico de esta asociación.

Case Report of the Incidence of Maternal Depression at a Community Level III, 39-Bed NICU

Postpartum depression (PPD) is a vastly undetected, underdiagnosed, and untreated mental health concern for all mothers with infants. Having an infant in the neonatal intensive care unit (NICU) has an even higher impact on mothers’ mental health, predisposing them to a higher rate of PPD. The aim of this project was to identify the incidence of PPD in a Level III NICU to determine appropriate intervention strategies. All mothers with NICU infants 14 to 20 days were invited to complete the 10-question Edinburgh Postnatal Depression Screening (EPDS). The EPDS was scored, and a NICU social worker discussed the results and offered resources for those with scores of ≥10. The incidence of positive screens at our institution was 71.9% for an EPDS score with a cutoff ≥10, and 50% for an EPDS score with a cutoff ≥13. Simple strategies, including routine screening, PPD groups, and NICU support groups, were implemented. All NICUs should know the incidence of mothers’ PPD. Acting on this information flows downstream to improving the health of the infant and family.