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Use of medical care in the Nation is greatest among the wealthy, and income-related inequality in use is highest among seniors

Despite publicly financed health insurance programs in the United States, such as Medicare and Medicaid, ability to pay influences the use of medical care. Higher income Americans of all ages use more care than their lower income counterparts irrespective of medical "need," and inequality in use is greatest among the elderly, according to a study supported by the Agency for Healthcare Research and Quality (HS10770).

Alex Y. Chen, M.D., M.S.H.S., of Children's Hospital Los Angeles, and Jose J. Escarce, M.D., Ph.D., of the University of California, Los Angeles, and RAND, analyzed data from the Household Component of the 1996-1998 Medical Expenditure Panel Surveys (MEPS). MEPS contains person-level data on health status, medical care expenditures, demographic characteristics, and household income. The researchers used the data to predict need-adjusted annual medical care expenditures per person by income level. They used the predictions to calculate Gini-like indices of inequality for all adults, working-age adults, seniors, and children 5 to 17 years of age. Their analysis was based on an adaptation of the Gini index, which is used by economists to quantify the degree of inequality in the distribution of income. A positive value of the index corresponds to inequality favoring the wealthy.

For all age groups, predicted expenditures per person, adjusted for medical need, generally increased as income rose. The index of inequality for all adults was +0.087; for working-age adults, +0.099; for seniors, +0.147; and for children, +0.067. If one assumes that the population was equally divided between poor and wealthy adults, the inequality index of +0.087 for all adults would correspond to the wealthy accounting for 58.7 percent of total medical care expenditures and the poor accounting for 41.3 percent. The expenditure gap would be greatest for seniors, whose inequality index of +0.147 corresponds to wealthy seniors accounting for 64.7 percent of total expenditures or 1.83 times as much as poor seniors (35.3 percent of care expenditures).

See "Quantifying income-related inequality in healthcare delivery in the United States," by Drs. Chen and Escarce in the January 2004 Medical Care 42(1), pp. 38-47.

Editor's Note: Another AHRQ-funded study on a related topic found that patients with chronic disease and other high-risk patients are responsible for the largest proportion of health care costs. The authors suggest that strategies to coordinate care for high-risk groups have the most potential to improve outcomes and maximize the investment of health care dollars. For more details, see Asplin, B.R. (2004, February). "Show me the money! Managing access, outcomes, and cost in high-risk populations" (AHRQ grant HS13007). Annals of Emergency Medicine 43(2), pp. 174-177.

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