Catastrophic health expenditures: a disproportionate risk in uninsured ethnic minorities with diabetes
Sebastian Linde1, Leonard E Egede2,3
1Department of Health Policy & Management, Texas A&M School of Public Health, 212 Adriance Lab Rd, College Station, Texas, TX, 77843, USA. slinde@tamu.edu.
Insights
Uninsured individuals, especially those with diabetes, face a significantly higher risk of catastrophic health expenditures (CHE). Racial and ethnic minorities experience even greater disparities in CHE risk, highlighting systemic inequities.
Area of Science:
- Health Economics
- Health Disparities
- Public Health
Background:
- Chargemaster prices in the US are substantially higher than negotiated rates for insured individuals.
- Uninsured patients are billed full chargemaster prices, increasing their risk of catastrophic health expenditures (CHE).
Purpose of the Study:
- To examine the risk of CHE across different insurance statuses.
- To investigate the impact of diabetes diagnosis on CHE risk.
- To explore racial and ethnic disparities in CHE risk.
Main Methods:
- Retrospective observational study using a nationally representative adult patient cohort from the Medical Expenditure Panel Survey (2002-2017).
- Logistic regression models were employed to estimate the risk of CHE.
- Analysis explored interactions between insurance status, diabetes, and race/ethnicity.
Main Results:
- Uninsured individuals had 5.9 times higher odds of CHE compared to insured individuals.
- Patients with diabetes had 1.1 times higher odds of CHE.
- Uninsured patients with diabetes had 9.5 times higher odds of CHE compared to insured patients without diabetes.
- Among the uninsured, non-Hispanic Blacks and Hispanics faced higher CHE risks than non-Hispanic Whites.
- Uninsured Hispanic patients with diabetes had a 39.3% higher likelihood of CHE than non-Hispanic white patients.
Conclusions:
- Uninsured patients, particularly those with diabetes, face significantly elevated risks of catastrophic health expenditures.
- Racial and ethnic minorities, especially among the uninsured with diabetes, experience disproportionately higher CHE risks.
- CHE may perpetuate structural economic and health disparities.
Background:
Chargemaster prices are the list prices that providers and health systems assign to each of their medical services in the US. These charges are often several factors of magnitude higher than those extended to individuals with either private or public insurance, however, these list prices are billed in full to uninsured patients, putting them at increased risk of catastrophic health expenditures (CHE). The objective of this study was to examine the risk of CHE across insurance status, diabetes diagnosis and to examine disparity gaps across race/ethnicity.
Methods:
We perform a retrospective observational study on a nationally representative cohort of adult patients from the Medical Expenditure Panel Survey for the years 2002-2017. Using logistic regression models we estimate the risk of CHE across insurance status, diabetes diagnosis and explore disparity gaps across race/ethnicity.
Results:
Our fully adjusted results show that the relative odds of having CHE if uninsured is 5.9 (p < 0.01) compared to if insured, and 1.1 (p < 0.01) for patients with a diabetes diagnosis (compared to those without one). We note significant interactions between insurance status and diabetes diagnosis, with uninsured patients with a diabetes diagnosis being 9.5 times (p < 0.01) more likely to experience CHE than insured patients without a diabetes diagnosis. In terms of racial/ethnic disparities, we find that among the uninsured, non-Hispanic blacks are 13% (p < 0.05), and Hispanics 14.2% (p < 0.05), more likely to experience CHE than non-Hispanic whites. Among uninsured patients with diabetes, we further find that Hispanic patients are 39.3% (p < 0.05) more likely to have CHE than non-Hispanic white patients.
Conclusions:
Our findings indicate that uninsured patients with diabetes are at significantly elevated risks for CHE. These risks are further found to be disproportionately higher among uninsured racial/ethnic minorities, suggesting that CHE may present a channel through which structural economic and health disparities are perpetuated.
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