chronic conditions or other health problems, one has to argue that affordability is different in some way for persons with chronic conditions other than simply their high level of spending.

Cunningham pointed out that the ACA does recognize different affordability thresholds based on income as a way of calculating the premium subsidies and even subsidies for cost-sharing. Although he said he is not advocating that there should be a different threshold for people with chronic conditions, such an argument could be made based on the findings of his research, which he presented. The research shows that high medical cost burdens for people with chronic conditions tend to persist over time, and these can often lead to greater accumulated debt, which in any given year creates more financial pressures than simply what they spend in that particular time period.

He stated that most of the findings in his presentation are based on 2008 data from MEPS, which were the most recently available data at the time of the workshop. Most data on expenditures and high medical cost burdens are based on annual estimates, and they are retrospective. But he has also used the panel component of MEPS to look at the persistence of high burden over a 2-year period. High financial burden is defined as out-of-pocket spending for both premiums and services that exceed 10 percent of family income, a definition that is consistent with his past work. Before-tax incomes are used, and assets are not included. Also, the sample is limited to nonelderly adults.

Health Insurance Coverage by Health Conditions

Using the conditions file and coding by the International Classification of Diseases, ninth revision (ICD-9), and the clinical classification codes that are in the MEPS, nonelderly adults were classified on the basis of their insurance status, whether they had any reported conditions during the year, whether they had acute conditions only, and whether they reported one, two, or three or more chronic conditions. The data show that nonelderly adults with multiple health problems were not necessarily at greater risk for high financial burden because of lack of coverage. In fact, among all the conditions looked at, they had the lowest uninsured rates of all the groups. In fact, people with no conditions had the highest uninsured rates, although one has to allow for the fact that there may be people with undiagnosed conditions who were uninsured in that group.

A higher percentage of people with multiple chronic conditions had public coverage (about 19.2 percent), which reflects disability coverage in Medicare and Medicaid. Yet two-thirds of people who had three or more chronic conditions had employer-sponsored private insurance.

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